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Soapie, Assessment and NCP on PAIN

Soapie, Assessment and NCP on PAIN

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Published by Ana

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Published by: Ana on May 24, 2010
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08/05/2013

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SOAPIE,Assessmentand NCP
Submitted to:Ms. Kristy Nillet Pongos R.N.Submitted by:Busa, Ana MarieNodalo, EvelynBSN II-C
 
SOAPIES
 
– “Magsinakit gihapon ako tiil labina kung molihok,” asverbalized by the patient.
O
 
– Seen patient lying on bed, without IV, conscious, coherent,grimaced face, swollen left leg, guarding behavior near the affectedpart. Pain usually occurs almost everyday located at the left legwith a duration of 1-3 minutes, characterized by a gnawing painaggravated by excessive movements and during standing, relievedby immobilizing the affected area and deep breathing exercises,treated by analgesics as ordered by physician, pain scale of 5.
A
 
– Alteration in comfort, pain related to tissue trauma secondaryto fracture
P
 
– To alleviate pain
I
 
– Approached patient in a pleasant manner, Encouraged patientto verbalize feelings about pain, Accepted clients description of pain, Instructed patient to immobilize the affected area, Taughtdeep breathing exercises, Provided diversional activities likesocialization, Assisted patient in proper positioning, Encouraged to
 
avoid exercise movements, Encouraged to have bedrest, Vital signstaken and charted.
E
 
– The patient was able to verbalize relief of pain felt from painscale of 5 to 3.

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