SOAPIE, Assessment and NCP

Submitted to: Ms. Kristy Nillet Pongos R.N. Submitted by: Busa, Ana Marie Nodalo, Evelyn BSN II-C

– “Magsinakit gihapon ako tiil labina kung molihok,” as

verbalized by the patient.


– Seen patient lying on bed, without IV, conscious, coherent,

grimaced face, swollen left leg, guarding behavior near the affected part. Pain usually occurs almost everyday located at the left leg with a duration of 1-3 minutes, characterized by a gnawing pain aggravated by excessive movements and during standing, relieved by immobilizing the affected area and deep breathing exercises, treated by analgesics as ordered by physician, pain scale of 5.


– Alteration in comfort, pain related to tissue trauma secondary

to fracture – To alleviate pain

– Approached patient in a pleasant manner, Encouraged patient

to verbalize feelings about pain, Accepted clients description of pain, Instructed patient to immobilize the affected area, Taught deep breathing exercises, Provided diversional activities like socialization, Assisted patient in proper positioning, Encouraged to

avoid exercise movements, Encouraged to have bedrest, Vital signs taken and charted.


– The patient was able to verbalize relief of pain felt from pain

scale of 5 to 3.


Physiologic Body Part
Muscle Function

Extraocular movements, intact bilaterally, both eyes is coordinated Patient was able to see examiner’s finger without moving his head Located at the midline of the face Red Glow observed during transluminal illumination Red Glow observed during transluminal illumination Dry lips and pale No discoloration, bleeding & swelling observed. Presence of saliva. A thin white costing is noted. Pale-pink in color, moist and absence of lesions. Both ears are brown in color, symmetrical. Absence of lesions. No discharges are observed. No discharges are observed. The patient can hear well at 3-5ft. from the bed Brown in color.




Peripheral Vision Nose Frontal Sinuses Maxillary Sinuses Mouth Lips Gums Tongue Sublingual area Ears

No pain felt during palpation No pain felt during palpation No pain felt during palpation


Firm. No pain felt.

Internal Auditory Acuity

Carotid Pulse is

San Lorenzo Ruiz College Ormoc City Nursing Care Plan
Name of Patient: Busa, Ana Marie October 18, 2009 Room #: 1 Problem/Needs Nursing Cues Diagnosis
Subjective: “Magsinakit jud ako tiyan”, as verbalized by the patient. Objective: -Guarding on the affected part -grimaced face and irritability were observed when pain occurs. -The part is located at the epigastric region of the abdomen with the duration of 1-2 mins. -It is characterized by crushing pain and aggravated by frequent movements. -It is relieved by deep Alteration in Comfort: Acute Pain related to disease process

Date: Scientific Basis
The patient with acute gastritis may have abdominal discomfort, headache, nausea, vomiting and hiccupping. In gastritis the gastric membrane becomes edematous and hyperemic and undergoes superficial erosion. It secretes a scanty amount of gastric acid, containing

Objective of Care
After 8 hrs of holistic nursing care, the patient will be able to verbalize reduce of pain from painscale of 6 to 3.

Nursing Action
1. Encourage verbalization of feelings about pain. 2. Accept patients description of pain

1. To assist patient to explore methods of control of pain. 2. Pain is a subjective experience and cannot be felt by others. Acknowledge the pain experience and convey acceptance of client’s response to pain. 3. To allocate pain

3. Position patient to the unaffected area. 4. Provide comfort measures

breathing exercises and diversational activities. -It is treated by analgesics as prescribed by the physician. Pain scale of 6.

very little acid. Superficial viceration may occur and can lead to hemorrhage. Source: Medical – Surgical Nursing by: Lemon & Burke p1011

(back rub, change of position). 5. Instruct the patient to do deep breathing exercises. 6. Encourage diversational activities (e.g. socialization). 7. Administer analgesic/anti – ulcer as ordered. Source: Nursing Pocket Guide by: Doenges 11th Edition p 500502

4. To promote nonpharmacolo gical pain management. 5. To distract attention and reduce tension. 6. To distract attention and reduce tension. 7. To maintain acceptable level of pain. Source: Nursing Pocket Guide by: Doenges 11th Edition p 500502

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