General Santos Doctor’s Medical School Foundation, Inc.

National Highway, General Santos City

NARCE, ALMERA ROSE F. MCN (RLE)

BSN-2A CI: MS. KENVYNE QUIDES-CALUGAY, RN, MAN

SOAPIE
DATE / TIME
31/08/2016 Ms. Dina Romero is a 26 years old postpartum mother. She
11AM was admitted last august 30, 2020 at 7:35 in the evening. She
gave birth on august 31,2020 at 9:43 in the morning. She was
forwarded in the OB ward at 11 in the morning with an IVF at
D5LR to run for 8hours, with flow rate 30 ggts/min, inserted at
the left metacarpal vein. Postpartal assessment findings are:
VS:T =36.6 degree Celsius, P= 78bpm, R=16cpm, BP=
115/75 mmHG; episiotomy done mediolaterally, uterus is firm
midline, sanitary pad in place and with moderate amount of
lochia; patient verbalized, “medyo masakit ang aking puerta.”
Rated pain as 6 out of 10. Postpartum orders: VS q 4 hours
and record; amoxicillin 500mg 1 capsule every 8 hours,
mefanamic acid 500mg 1 capsule every 6 hours PRN for
11:01AM pain.
11:30AM
S = “medyo masakit ang aking puerta.” as verbalized.
- Rated pain as 6 out of 10
O= VS: T =36.6 degree Celsius, P= 78bpm, R=16cpm, BP=
115/75 mmHG
- episiotomy done mediolaterally
11:45AM
- uterus is firm midline
- with moderate amount of lochia
A = Acute pain related to episiotomy as evident by pain scale
of 6.
P = Within 8 hours of nursing interventions, patient will be
able to:
- Report a decrease of pain from 6 to 3.
- Use of pain-relief strategies proper breathing and
relaxation techniques.
I = Established rapport.
- Monitor the vital signs
- Assess the episiotomy wound for abnormal discharge
signs of infection.
- Record and time the frequency, intensity, interval and
 duration of pain related to episiotomy.
- Administer amoxicillin 500mg 1 capsule every 8 hours,
mefenamic acid 500mg 1 capsule every 6 hours PRN
for pain
- Encourage verbalization of feelings about pain such as
concern about tolerating the pain
- Provide for a therapeutic environment that is quiet,
adequately ventilated, dimly lit, and free of distractions.
E = After 8 hours of nursing interventions, goal met. Patient
was able to:
- Maintain vital signs within normal range:
T:36.5 PR:90cpm RR:20bpm BP:100/80
- Verbalized pain within tolerable limits
- Rated pain from 6 to 3
- Able to exhibit strategies proper breathing and
relaxation techniques.

ALMERA ROSE NARCE,SN