B.

NURSING MANAGEMENT
a) Actual SOAPIERs

11-26-09
S- Ø
O- received patient on bed in a lying position, sleeping, with an ongoing IVF # 2 PNSS
1L x 100cc/hr at 800 cc level, infusing well on the right arm. Side drip 1 # 2, Isoket drip
(D5W 90 cc + isoket 10mg/ soluset) x 1.5 mg/hr at 45 cc level. With oxygen hooked via
nasal cannula regulated at 2 lpm, with condomcatheter attached to urine bag. On
continuous cardiac monitoring, (-) desaturation, (-) complaints of chest pain, with
productive cough. With GCS of 15 ( E4V5M6) . initial VS: T- 35.8 P- 76 bpm R- 18 bpm
BP- 100/70 mmHg

A- Ineffective airway clearance related to retained tracheobronchial secretions.

P- After 3-4 hours of NPI, patient will maintain airway patency.

I- Established rapport

- Monitored and recorded VS, I and O q 1 hour

- Auscultated breath sounds

- Assessed for presence of adventitious breath sounds

- Kept patient on moderate fowler’s position

- Enfroced diet: soft, low salt and low fat

- FBS and lipid profile done

- Provided comfort measures such as stetching the linens

- Provided calm and warm environment for rest

- HGT result at 12 noon is 148 mg/dl. Dr Garcia aware of the result

- Regulated IVF and side drip as ordered

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 - Due meds given

- Seen o round by Dr. Alfonso with orders made and carried out: HGT- 179mg/dl
kindly give 5 “u” HR IV and 5 “u” SQ given at 7:30 am c/o NOD. ECG tracing- Sinus
Rhythm. May d/c lidocaine drip-done.

- Seen on rounds by Dr. Cunan with orders made and carried out: May shift to
Pantuloc IV 40 mg/tab OD- shfted and given at 8 am. Shifted Simvastatin to
Atorvastatin 40mg/tab OD at HS- shifted.Start Mixtard 20 “u” SQ in pm. Aspirin 80
mg/tab OD- given and hold. Vastarel MR 35 mg/tab BID given at 8 am.

- Seen o n rounds by Dr. Garcia with orders made and carried out: (+) bibasal
rales, shift IV to D5W 500 cc x 20 cc/hr- shifted at 9:40 am. Give Lasix 20 mg SIVP
now- given at 10am. Patient vomitted once previously ingested food at 8: 30 and
11:30 am. Dr Garcia aware and updated Dr Cunan and ordered to hold Aspirin- done.
Start Clorpidogrel (Winthdrop) 75 mg/tab Od. Repeat ptassium-done.

E- Goal met. Patient maintained airway patency.

11-27-09

S- Ø
O- received patient on bed in a lying position,awake, conscious and coherent, with an
ongoing IVF # 3 D5W 500ccx 20cc/hr at 300cc level infusing well on the right hand.
With oxygen hooked via nasal cannula regulated at 2 lpm, with condomcatheter
attached to urine bag. On continuous cardiac monitoring, (-) desaturation, (-) complaints
of chest pain, with productive cough.Needs assistance when moving, with enforced
bedrest, limited ROM. With GCS of 15 ( E4V5M6) . with initial VS:T- 35.5 P- 67 bpm R-
20 bpm BP- 100/60 mmHg

A-Impaired physical mobility related to bedrest

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P- After 3-4 hours of NPI, patient will participate with use of activities within his capacity.
I- Established rapport

- Monitored and recorded VS, I and O q 1 hour

- Kept patient on moderate high baack rest

- Enforced patient to limit fluid intaketo 1L/day

- Enfroced diet: soft, low salt and low fat

- Provided comfort measures such as stetching the linens and raising side rails

- Assisted patient in turning ng moving

- Assisted patient in feeding

- Asssited in changing the diaper

- Weighed the diaper and recorded the patient’s urine output

- Provided calm and warm environment for rest

- For 2D echo doppler- doneat 10am

- HGT result at 12 noon is 75 mg/dl. Dr Chua aware of the result

- Regulated IVF and side drip as ordered

- Due meds given

- Seen on round by Dr. Garcia with orders made and carried out: Last dose of
Lasix today then start Aldazide 25 mg/tab BID

E- Goal met. patient participated with use of activities within his capacity

11-28-09

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S- Ø
O- received patient on bed in sleeping, with an ongoing IVF # 4 D5W 500ccx 20cc/hr at
300cc level infusing well on the right hand. With oxygen hooked via nasal cannula
regulated at 2 lpm, with condomcatheter attached to urine bag. On continuous cardiac
monitoring, (-) desaturation, (-) complaints of chest pain, with productive cough.Needs
assistance when moving, with enforced bedrest, limited ROM. With GCS of 15
( E4V5M6) . with initial VS:T- 36 P- 77 bpm R- 20 bpm BP- 100/70 mmHg

A-Activity intolerance related to weakness

P- After 3-4 hours of NPI, patient will participate with use of activities within his capacity.
I - Established rapport

- Monitored and recorded VS, I and O q 1 hour

- Assessed general condition

- Kept patient on moderate high baack rest

- Enforced patient to limit fluid intaketo 1L/day

- Enfroced diet: soft, low salt and low fat

- Provided comfort measures such as stetching the linens and raising side rails

- Assisted patient in turning ng moving

- Assisted patient in feeding

- Provided calm and warm environment for rest

- HGT result at 12 noon is 75 mg/dl. Dr Chua aware of the result

- Regulated IVF and side drip as ordered

- Due meds given

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 - Seen on round by Dr. Garcia with orders made and carried out: for transfer to
room of choice.

E- Goal met. patient participated with use of activities within his capacity.

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