NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines Telephone
No.: (064) 200-3631 Fax No.: (064) 200-4131

Name of Student: Denesa Joy Brana Year/Level: BSN1-A

Date Submitted: March 22, 2022 Score: ____________

ACTIVITY 9

PART I. DIRECTION: Write a sample S-O-A-P-I-E charting and FOCUS charting based on the
scenario and situation provided. Write your answer in the table provided.

A. Scenario:
Ms. Deborah, a 58-year old patient, was admitted to the critical care unit (CCU) 3 days
ago under Dr. Franco's service due to the sudden onset of substernal chest pain that radiates to
the back, neck, and jaw. Few hours before the patient was admitted, she felt an indescribable
epigastric pain accompanied by a feeling of indigestion. The condition subsided after the patient
laid down on the sofa. An hour before admission, she had a heavy feeling that something was
pressing her sternum hard and began to rub her chest with her fist clenched. A few minutes later,
the patient started to feel uneasy and started to have cold sweats accompanied by mild shortness
of breath. The persistence of the condition prompted the patient to go to the emergency
department.
Upon arrival in the emergency department, the patient's vital signs were: BP –
80/40mmHg, CR – 120bpm, RR – 26cpm, T – 35.7 degrees C, o2 sat – 92%, and capillary refill
time of 2 seconds. The ER doctor ordered the staff to start all emergency medications and
procedures and immediately acquire all necessary laboratories and diagnostics needed by the
patient.
Upon taking the patient's history, it revealed that five (5) years ago, Ms. Deborah was
diagnosed with hypertension and diabetes mellitus type II. Furthermore, she had a sedentary
lifestyle and drank alcohol regularly. Moreover, she is taking immunosuppressive drugs after she
had a mastectomy a year ago. Upon tracing the familial lineage, her grandparents on both sides
also have diabetes mellitus, and her father has ischemic heart disease.
During the 2nd day of admission to the critical care unit (CCU), the patients' family started
to worry about the expenses and decided to transfer the patient to the medical ward the
following day.

B. Situation:
You are on the 3rd day of the patient's admission in which you are on duty in the female medical
ward from 7 am-3 pm, and you received the patient from the CCU.
You received the following endorsement from the outgoing NOD: "endorsing patient
Deborah transferred from CCU today under the service of Dr. Franco, admitted due to sudden
onset of substernal chest pain. The admitting diagnosis is Acute myocardial infarction.
You went to the patient's room and assessed her condition. Vital signs revealed: BP100/70
mmHg, CR – 98 bpm, RR – 20 cpm, T – 37 degrees Celcius, and Oxygen saturation at 97%.
 At one (1 pm), you gave your patient medications that is intended for her. Simultaneously,
Dr. Franco made the rounds and ordered to change her intravenous fluid to heplock and carried
out the order. And just before your shift ended, your patient shared a personal insight regarding
his condition: "Nurse, di ko na bal-an kung anu himuon ko, dako nagid kaayo gastos namun diri
sa hospital". You responded correctly to the patient's statement and made her calm her mind. At
2pm, the patient shared with you tha: “Nurse, tong mga nag ligad na mga adlaw wala gd ko
gana magkaon, pero subong kelangan ko gid magkaon sing healthy na pagkaon para maka
recover dayon ang lawas ko”. You agreed with the patient’s statement and offered to assist her
in any way possible for her to recover from her condition.
As your conversation went along, the patient suddenly cried and shared with you that she had
been mistreated by her relatives when she was young and that, her parents did not know what
she had gone through with them. Also, during her high school days, she had been bullied a lot
by her classmates and could not forget the feeling up until this moment. You continued to talk
with your patient, made her calm and the patient suddenly fell asleep.

A. SOAPIE CHARTING

S: Chest pain as evidence by rubbing her chest with fist clenching.

O: BP: 80/40mmHG, PR: 120bpm, RR: 26cpm, T: 35.7degrees C, o2 sat:-92%, and capillary refill
2 seconds, nausea, and diaphoresis.
A: Acute chest pain related to coronary artery occlusion
P: Short Term
After 8 hours of nursing interventions, the client will verbalize relief of chest pain
Long Term
After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability
I: Administered oxygen therapy to balance the myocardial oxygen supply.
Monitor blood pressure and pulse.
Provide Light Meals.
E: The goal was met, after 8 hours of proper nursing interventions the patient reported no signs
of pain.
B. FOCUS CHARTING

FOCUS (PES) DATA, ACTION, RESPONSE (DAR)

Acute Myocardial Infarction D– patient experience a sudden onset substernal

chest pain and acute myocardial infarction
with blood pressure of 100/70 mmHg,
respiratory rate of 20 cpm, T – 37 degrees
Celcius, and Oxygen saturation at 97%

A– gave patient medications that is intended for

her, gave intravenous fluid to heplock and
offered to assist her in any way possible for
her to recover from her condition

R– after giving nursing intervention the patient

suddenly cried and shared with you that she
had been mistreated by her relatives, made
the patient calm and the patient suddenly fell
asleep. Goal met.