1.

Actual SOAPIE

November 13, 2010

S-O

O-Received on sitting position, awake, conscious and coherent, with intact heplock on
left hand, with pale palpebral conjunctiva, with pale oral mucous membranes, presence
of non-palpable rashes on both lower extremities, with headache, afebrile, and absence
of DOB with initial VS of T= 36.6, P=80 bpm, R=19 bpm, BP= 130/100 mmhg

A-Ineffective cardiac tissue perfusion r/t interruption of blood flow

P-after 4 hours of nursing interventions, the patient will maintain adequate tissue
perfusion

I- Established a good working relationship with the patient and SO

-Assessed general condition and obtained history of the disease condition

-Obtained and recorded VS

- Provided safety and comfort measures such as stretching the bed linens and raising
the side rails.

-Instructed to limit activities that could cause injury such as frequent sitting/ standing

-Due meds given

-Needs attended

E- Goal met AEB the patient maintained adequate tissue perfusion as evidenced by BP
of 120/80 mmhg
November 17, 2010

S-O

O-Received on sitting position, awake, conscious and coherent, with intact heplock on
left hand, with presence of pallor in his mucous membrane, with swollen and painful palpebral
and bulbar conjunctiva, with positive eye discharge, presence of non-palpable rashes on
both lower extremities, afebrile, and absence of DOB with initial VS of T= 36.7, P=73
bpm, R=22 bpm, BP= 110/70 mmhg

A-Ineffective protection related to drug therapy (corticosteroids)

P-after 4 hours of nursing interventions, the patient will not develop further infection

I- Established a good working relationship with the patient and SO

-Assessed general condition and obtained history of the disease condition

-Obtained and recorded VS

- Provided safety and comfort measures such as stretching the bed linens and raising
the side rails.

-Instructed proper hygiene to prevent spread of infection

-Provided health teachings to patient’s SO to prevent spread of infection

-Due meds given

-Needs attended

E- Goal met AEB the patient did not develop further infection
November 18, 2010

S-O

O-Received on supine position, awake, conscious and coherent, with intact heplock on
left hand, with presence of pallor in his mucous membrane, with swollen and painful palpebral
and bulbar conjunctiva, with positive eye discharge, presence of non-palpable rashes on
both lower extremities, afebrile, and absence of DOB with initial VS of T= 37.1, P=78
bpm, R=20 bpm, BP= 100/70 mmhg

A- Risk for spread of infection

P-after 4 hours of nursing interventions, the patient will not develop further infection

I- Established a good working relationship with the patient and SO

-Assessed general condition and obtained history of the disease condition

-Obtained and recorded VS

- Provided safety and comfort measures such as stretching the bed linens and raising
the side rails.

-Instructed proper hygiene to prevent spread of infection

-Provided health teachings to patient’s SO to prevent spread of infection

- Emphasized to patient to avoid rubbing his eyes most especially when they are long
and dirty

-Due meds given

-Needs attended

-Endorsed

E- Goal met AEB the patient did not develop further infection