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SOAPIE Sample Chart

The client presented with a non-painful cough producing phlegm. On assessment, the client exhibited restlessness, productive coughing, and forced coughing, indicating an ineffective airway clearance due to accumulated sputum. The plan was to instruct the client on increasing fluid intake, deep breathing exercises, proper coughing techniques, and administer prescribed antitussives over 8 hours to help the client learn to loosen and expectorate phlegm effectively.

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Eda Del Rosario
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2K views1 page

SOAPIE Sample Chart

The client presented with a non-painful cough producing phlegm. On assessment, the client exhibited restlessness, productive coughing, and forced coughing, indicating an ineffective airway clearance due to accumulated sputum. The plan was to instruct the client on increasing fluid intake, deep breathing exercises, proper coughing techniques, and administer prescribed antitussives over 8 hours to help the client learn to loosen and expectorate phlegm effectively.

Uploaded by

Eda Del Rosario
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
  • URTI Sample Charting: Details a sample charting method for Upper Respiratory Tract Infection using the SOAP format, capturing subjective and objective data, assessment, and planning.

URTI sample charting

S hindi masakit ung pagubo ko pero may plema as verbalized by the client

O Restlessness; productive cough; forced cough

A Ineffective airway clearance related to accumulation of sputum as evidenced by


productive cough
P After 8 hours of nursing intervention client will be able to learn ways to loosen
phlegm and effectively expectorate sputum.
I instruct the client to increase fluid intake to decrease viscosity of sputum; teach
client to do deep breathing exercises and proper coughing exercises to mobilize the
secretions; administer antitussives as prescribed by the physician.
E After 8 hours of nursing intervention client is able to effectively expectorate
sputum and learn techniques to loosen phlegm.

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