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NURSING MANAGEMENT (ACTUAL SOAPIEs)

SEPTEMBER 08,2015
S=
O=Received lying on bed, oriented to time, place and person, weakness
noted, with cold clammy skin, pallor noted, with slow capillary refill, with and
initial vital signs of T: 36.4, PR: 90, RR: 25, BP: 120/80
A=Decreased Cardiac Output related to Decreased Myocardial Contractility
P= After 2 hours of nursing interventions, the patient will be able to verbalize
knowledge of the disease process, individual risk factors, and treatment plan.
I=
> Established rapport
> Monitored and recorded vital signs
> Provided bed side care
> Oral Medications given and noted
> Reiterated low salt low fat diet
> Explained the purpose of the activity ordered, the consequences of not
following such diet and how it will be implemented
> Provided proper positioning
> Assisted the client in doing any activities
> Document response of the patient
E= patient verbalized understanding of the condition and treatment plan
SEPTEMBER 09, 2015
S=
O= Received patient on bed on a semi fowlers position, oriented to time
place and person, with an indwelling foley catheter attached to a urine bag
draining yellow urine at 860 cc level, cold and clammy skin, with pallor noted,
with altered motor function, with vital signs as follows: T:36.7, PR: 70, RR: 25,
BP: 140/90
A= Ineffective tissue perfusion related to hypertension
P= After 2 hours of nursing interventions, the patient will verbalize
understanding of condition, side effects of medications, and therapy
regimen.
I=
>Monitored and recorded vital signs

> Provided bed side care


> Oral Medications given and noted
> Reiterated low salt low fat diet
> Turned the patient from side to side
>Measured capillary refill
> Palpated arterial pulses
>Noted clients nutritional status
>Encouraged ambulation
>Discourage sitting and standing for an extended periods of time, wearing
constrictive clothing
E= Demonstrated an adequate coronary perfusion as individually appropriate
SEPTEMBER 09, 2015
S=
O= Received patient on bed on a semi fowlers position, oriented to time
place and person, with an indwelling foley catheter attached to a urine bag
draining yellow urine at 800 cc level, weakness noted, dysrhythmias, pallor
noted, with an initial vital signs as follows: T: 36.9, PR: 65, RR: 28, BP: 140/90
A=Activity intolerance related to generalized weakness
P= After 2-4 hours of nursing interventions, the patient will demonstrate an
increase in tolerance in activity
I=
>Monitored and recorded vital signs
> Provided bed side care
> Turned patient from side to side
> Provided health teachings
> Reiterated low fat low salt diet
> Emphasized to limit oral fluid intake for 1L per day