UNIVERSITY OF THE PHILIPPINES MANILA

The Health Sciences Center

COLLEGE OF NURSING
Sotejo Hall, Pedro Gil Street, Manila
N10 Nursing Foundations I
SOAPIE DOCUMENTATION
Name of Student: Jubilee Christiene M. Ang Date: November 9, 2015 and Time: 10:00 A.M.
Name of Client: Victoria Cureg Age: 54 Sex: F Civil Status: Single

SUBJECTIVE OBJECTIVE ANALYSIS PLAN IMPLEMENTATION EVALUATION

Hihiga na ako, T-36.7C Nursing Diagnosis: Assist client The nurse had The client
kasi ang sakit na (Axilla) Impaired Comfort towards assisted the preferred lying
ng binti ko, PR- 70 bpm related to prolonged proper bed- client towards in the bed
nangangawit RR- 21 period of sitting positioning proper bed- sideways and
na. breaths per The client feels hip which positioning. felt more
Nakaupo ako minute and leg discomfort prevents her The nurse also comfortable
kanina pang Blood after a prolonged from feeling explained the upon being
8:00 am. Pressure- period (2 hours) of more hip and proper lying assisted by the
Ang talagang 130/80 sitting on a chair leg posture while nurse.
naka-aapekto sa BMI Status: beside her bed. discomfort. assisting the
akin yung Obese 1 The client client.
pagsakit ng Capillary verbalizes that her
tuhod ko tsaka Refill, 3 legs get sore easily The nurse
balakang kapag seconds because of her massaged the The client
matagal akong Weak current body and Massage the legs and feet verbalized Oo,
nakaupo o peripheral its amount of body clients legs of the client mas nawala na
nakatayo, o fat. and feet to Nurse taught ang sakit after
pulses at
kaya The client has improve the client and the massage
popliteal,
naglalakad. weak peripheral blood flow clients son
Ganito kasi ako
posterior pulses particularly about the
and to
kaya madali tibial and at the lower region release massage
akong dorsalis of her body. Her tension. techniques to
mangawit. Dahil pedis artery capillary refill soothe leg
sa sa sobrang Client was duration is 3 pain.
bigat ko. only sitting seconds. This
(referring to her on a chair implies a decrease The client felt
body) beside her in amount of blood The nurse had more
 Hindi ko bed from flow at the leg assisted the comfortable
maexplain yung 8:00 A.M. to region. Perform ROM clients leg and relieved
sakit, pero 10:00 P.M. exercises while after all the
parang yung (approx. 2 with the performing the nursing
normal lang na hrs) assistance of ROM leg interventions
pakiramdam Client was the nurse in exercises made by the
kapag pagod trying to order to nurse.
ka. soothe her increase
legs by blood flow
caressing
her legs
(hinihimas-
himas)
Client lied
down on her
bed