Need fast answer:How to write this SOAPIE?

I have moved your post to the student assistance forums, if you give us some ideas of how much you have done towards this questions and maybe the specific areas you are struggling with then we can point you in the right direction rather than just answering the question for you.

You mention nursing diagnosis, what would your thoughts be around this, do you think this has a nursing diagnosis, if so why don't you try to explain what and why you think that.

Your SOAPIE stands for

S= subjective findings

O= objective findings

A= assessment

P= plan

I= interventions

E= evaluation

Have a look at Daytonites post here

It's a wonderful post and gives some examples that will help you.

Also take a look at this post, it gives suggestions for nursing diagnosis for phlebitis

i have one question: write one soapie is following this pateint's chart.

scenario: juan reyes has now been hospitalized for one week. blood cultures were positive for streptococcus pneumonia; juan's doctor also did a spinal tap on juan which was positive for the same organism. his medical diagnosis is pneumococcal meningitis. he was started on an antibiotic medication called vancomycin 1 gm to be given every 12h and ceftazidime 2 gm every 8h intravenously. mr. reyes was confused initially when he was placed in respiratory isolation, but now, with negative cultures, he has been transferred out of isolation to a medical floor room.

you are assigned to care for juan this shift and you enter his room:

l his facial skin is warm, pink, and dry.

l he says, "that iv site in my right arm sure hurts today."

l his oral temperature is 98.8, r=18, p=80, bp 110/80

l his breathing is regular and his lung fields have normal-sounding air flow on both sides of the back and front of his chest.

l skin around the iv catheter is red, not swollen, but tender to touch.

l the iv is dripping at an 80cc per hour rate according to the meter in the iv ac iv pump.

l mr. reyes says that he no longer has a headache, neck ache, or photophobia.

l he eats only a small amount of breakfast saying "i'm still not very hungry, my stomach gets upset with heavy foods like fried eggs and panckes."

l he get up to the bathroom with your help and urinates clear, straw-colored urine.

please teach how to write this soapie.

what you are failing to see is that this assignment is not just about writing the soapie note. the soapie note is what you will end up with, but to write the soapie note there are some things that you must do first. (1) there must be a numbered list of the patient's current problems that are listed in chronological order. each problem is then referred to by its number when you are writing your soapie note about it. (2) to obtain this numbered list means that you must diagnose his nursing problems from the information provided in the scenario. nursing diagnoses (nursing problems) are based upon the evidence that you have to support them. you should read about shock and pneumococcal meningitis in order to understand the etiologies of some of the nursing diagnoses:

http://www.merck.com/mmpe/sec06/ch067/ch067b.html

http://www.merck.com/mmpe/sec16/ch218/ch218b.html.

i was able to determine that the patient has 7 problems (nursing diagnoses as well as the data from the scenario that matches with them, except for one--the acute confusion diagnosis. he was confused upon admission. you are free to disagree with me if you feel i missed something. i put this together fast and might not have thought something through very well. also, a full care plan with goals and interventions really should be in place to refer to when doing the charting for this.

the problem list:

1. ineffective tissue perfusion, cerebral and gastrointestinal r/t impaired transport of oxygen and vasoconstriction of peripheral vessels
   
2. ineffective airway clearance r/t excessive secretions
   
3. deficient fluid volume r/t fluid loses
   
4. hyperthermia r/t inflammation of meninges and lung
   
5. impaired mobility r/t inflammation and tension on spinal nerve roots
   
6. acute pain r/t inflammation of meninges and nuchal rigidity
   
7. disturbed sensory perception, visual r/t altered sensory perception
   
8. acute confusion r/t compromised cerebral oxygenation and tissue swelling
   

now, the soapie note includes the following information:

you can see an example of this style charting posted here: https://allnurses.com/forums/2430899-post6.html

to proceed with your charting means you not only have to identify the how the assessment data fits in with the problem (nursing diagnosis), but what nursing interventions you will perform to do something about them--if anything. so, here is my take on this. i would encourage you not to copy what i have done. i may be wrong in some cases and i don't know what your nursing program focuses on. this is what i came up with. . .