ACTUAL SOAPIERs

January 4,2010

S Ø
>
O Received on bed, conscious and coherent with an ongoing IVF of D5NR 1L x
> 120 cc/hr @ 280 cc level, patent and intact infusing well on left metacarpal
with no signs of infiltrations; with intact indwelling foley catheter connected to
urine bag at 1000 cc level draining a amber colored urine; dry and intact
dressing on his right hip; no complaint of dizziness and headache; anicteric
sclera; moist buccal mucosa; no difficulty of breathing; no signs of chest
retractions; capillary refill time of less than 3 seconds; with good skin turgor;
afebrile. V/S taken as follows: T: 36.2 C, PR: 85 bpm, RR: 19 cpm, BP:
140/70mmHg
A Risk for infection related to inadequate primary defenses (broken skin)
>
P After 4 hours of nursing interventions, the patient will be able to identify
> interventions to prevent or reduce risk for infection.
I> > Establihed rapport
> Monitored and recorded v/s
> Assessed general condition
> Placed to semi fowlers position
> Provided health teaching such as to follow exercise program
> Identified necessary changes in lifestyle and assisted client to
incorporate disease management to ADL’s
> Stressed proper handwashing techniques by all caregivers between
clients
> Provided regular catheter care
> Encouraged diet as tolerated, especially foods rich in protein and
Vitamin C for faster wound healing and tissue repair
> Emphasized importance of taking antibiotics
> Regulated IVF as indicated
> Due meds given
> Needs attended
E> Goal met as evidenced by the patient is able to identify interventions to
prevent or reduce risk for infection.
January 5, 2010
S> Ø
O> Received on bed, conscious and coherent with an ongoing IVF of D5NSS 1L x 120 cc/hr
@ 890 cc level, patent and intact infusing well on left metacarpal with no signs of
infiltrations; with intact indwelling foley catheter connected to urine bag at 900 cc
level draining a amber colored urine; dry and intact dressing on his right hip; no
complaint of dizziness and headache; anicteric sclera; moist buccal mucosa; no
difficulty of breathing; no signs of chest retractions; capillary refill time of less than 3
seconds; with good skin turgor; afebrile. V/S taken as follows: T: 36.4 C, PR: 79 bpm,
RR: 21 cpm, BP: 140/70 mmHg
A> Impaired skin integrity related to mechanical factors ( compression screw hip fixation)
P> After 4 hours of nursing interventions, the patient will be able to display timely healing
of surgical incision without complications.
I> > Establihed rapport
> Monitored and recorded v/s
> Assessed general condition
> Placed to semi fowlers position
> Changed position every 2 hours
> Provided health teaching such as to follow exercise program
> Identified necessary changes in lifestyle and assisted client to incorporate
disease management to ADL’s
> Stressed proper handwashing techniques by all caregivers between clients
> Provided regular catheter care
> Encouraged diet as tolerated, especially foods rich in protein and Vitamin C for
faster wound healing and tissue repair
> Kept the incision area clean and dry
> Reviewed measures to prevent spread infection
> Regulated IVF as indicated
> Due meds given
> Needs attended

E> Goal met as evidenced by the patient is able to display timely healing of surgical
incision without complications.
January 6, 2011

S> Ø
O Received on bed, conscious and coherent with an ongoing IVF #6 of D5NR 1L x
> 120 cc/hr @ 60 cc level, infusing well on left metacarpal vein with no signs of
infiltrations; with indwelling foley catheter connected to urine bag with 600 cc
amber colored urine, with dry and intact dressing on his right hip, with
antiembolic stockings, with capillary refill time of 2 seconds, with pink
palpebral conjunctiva, with initial vital signs of T: 36.9oC, PR: 86 bpm, RR: 22
cpm, BP: 150/80mmHg
A Impaired physical mobility related to musculoskeletal impairment
>
P After 4 hours of nursing interventions, the patient will be able to verbalize
> understanding therapeutic regimen

I> > Establihed rapport

> Monitored and recorded vital signs
> Assessed patient’s general condition
> Assessed surgical site
> Provided PM care
> Regulated and monitored IVF as ordered
> Provided safety measures such as raising side rails
> Provided comfort measures such as keeping bed wrinkle free
> Instructed to increase oral fluid intake
> Instructed to position in a semi-fowler position
> Instructed to perform coughing and breathing exercises
> Kept back dry
> Meds given
> Needs attended

E> Goal met, the patient verbalized understanding of therapeutic regimen

January 07, 2011
January 08, 2011

S Ø
>
O Received on bed, conscious and coherent with an ongoing IVF #7 0.9 NaCl 1L x
> 30-31 gtts/min @ 60 cc level, infusing well on left metacarpal vein with no
signs of infiltrations; with indwelling foley catheter connected to urine bag with
1200 cc amber colored urine, with dry and intact dressing on his right hip, with
antiembolic stockings, skin is warm to touch, with initial vital signs of T: 38.7 C,
PR: 91 bpm, RR: 25 cpm, BP: 120/80mmHg
A Hyperthermia
>
P After 4 hours of nursing interventions, the patient’s temperature will achieve
> and maintain within normal range.
I> > Monitored and recorded vital signs
> Assessed patient’s general condition
> Assessed surgical site
> Provided AM care
> Regulated and monitored IVF as ordered
> Provided tepid sponge bath q15 minutes
> Provided safety measures such as raising side rails
> Provided comfort measures such as keeping bed wrinkle free
> Instructed to increase oral fluid intake
> Instructed to position in a semi-fowler position
> Instructed to perform coughing and breathing exercises
> Kept back dry
> Meds given
> Needs attended
> Above intravenous fluid consumed; hooked, 0.9 NaCl @ 5 PM and
regulated @ 31 gtts/min
E> Goal met as evidenced by the patient’s temperature achieved and maintained
within normal range.
Bibliography
Orthopedic Nursing Manual Second Edition by Artemio M. Buitre Jr., R.N.
S “I still have difficulty doing my usual routine”
>
O Received patient undergoing session with physical therapist, conscious and
> coherent, with pain scale of 4/10, with intact and dry dressing at the surgical
site, with capillary refill time of 2 seconds, with pink palpebral conjunctiva, (+)
dizziness, (-) DOB, (-) headache, with good skin turgor, complaint of weakness,
with initial vital signs of T: 36.5oC, P: 88 bpm, R-22 cpm, BP- 120/80 mmHg
A Activity intolerance related post surgical procedure
>
P After 4 hours of nursing interventions, the patient will be able to identify
> techniques to enhance activity tolerance
I> > Monitored and recorded vital signs
> Assessed patient’s general condition
> Assessed surgical site
> PM care rendered
> Regulated and monitored IVF as ordered
> Noted client report of difficulty accomplishing task
> Assisted client in performing his ADL’s such as helping him go to the
comfort room and move out of his bed
> Provided safety measures such as raising side rails and instructing SO to
stay with him
> Provided comfort measures such as stretching bed linens and keeping it
wrinkle free
> Encouraged to increase oral fluid intake
> Provided health teachings to eat protein rich foods for bone and muscle
repair
> Kept back dry
> Meds given
> Needs attended
E> Goal met as evidenced by the patient identified techniques to enhance activity
tolerance.
Lippincott’s Review Series Pathophysiology Second Edition by Catherine Paradiso
http://www.imaginis.com/osteoporosis/osteo_affectswhom2.asp
http://www.medicinenet.com/fracture/article.htm
http://www.fnri.dost.gov.ph/index.php?option=content&task=view&id=749
http://en.wikipedia.org/wiki/Bone_fracture
http://www.iofbonehealth.org/facts-and-statistics.html
http://www.wrongdiagnosis.com/f/fractures/stats-country.htm
http://www.sciencedaily.com/releases/2009/02/090218114320.htm
http://www.medical-look.com/human_anatomy/systems/Skeletal_System.html