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(Sample SOAPIE / Nursing care plan)

Patient’s Name: Miss. M T

Case: Post CS
Room: 222

S >“Sumasakit yung tahi ko” as verbalized by the patient.

> Pain Scale of 6/10

O > (+) Facial Grimace

> Irritability
> Restlessness

A > Acute pain related to post cs

P > At the end of 8 hours shift, patient will report relived pain from
6/10 to 4/10

I > Provide quite environment

> Encouraged to do deep breathing exercise
> Encouraged adequate rest period
> Encouraged to support the affected area upon movement

E > Goal met, patient’s pain decreased from 6/10 to 4/10