Need fast answer:How to write this SOAPIE?

queenjean · Nov 23, 2008

Do you not understand what SOAPIE means? What problems or questions do you have with it?

Why don't *you* write out what you think the answer is and post it. Otherwise, we'd just be doing your homework for you, and that is typically frowned upon.

PiscesY · Nov 23, 2008

I know.S=subject,O=object,A=diagnosis,P=plan,I=intrevention,E=evaluation.

But I'm not sure I can write correct SOAPIE,because my teacher is not clearly teach us how to write it in the class, just by ourself, so I post want to somebody can teach and help me.

Do you not understand what SOAPIE means? What problems or questions do you have with it?
Why don't *you* write out what you think the answer is and post it. Otherwise, we'd just be doing your homework for you, and that is typically frowned upon.

PiscesY · Nov 23, 2008

I wanna know how about the patient's IV problem,because nurse saw the patient's "skin around the IV catheter is red, not swollen, but tender to touch".So,I just want to know about IV need diagnosis or not?If need,what's this diagnosis,also have to follow the NANDA.

Who can help me get answer? Thank you

allnurses Guide · Nov 23, 2008

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.

PiscesY · Nov 23, 2008

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.

What are you talking about,I just wanna know how to write this SOAPIE.I don't have any wrong thinking

If you don't want to help me, please don't say it. ok? I just need help,only help.

PiscesY · Nov 23, 2008

I just want to somebody can help me write a correct SOAPIE.

Who can help me? Why only reporach me? What is wrong?

VickyRN, MSN, DNP, RN · Nov 23, 2008

I just want to somebody can help me write a correct SOAPIE.
Who can help me? Why only reporach me? What is wrong?

Show us what you have done so far, and we will be glad to help you. Don't get defensive if we want to see your attempted work first.

These resources or threads may be of immense help to you:

http://www.medicalassistant.net/soap_note.htm

https://allnurses.com/forums/f223/pediatric-soap-notes-179647.html

https://allnurses.com/forums/f34/soap-note-question-143068.html

Best wishes to you :)

PiscesY · Nov 23, 2008

I need what is correct SOAPIE? For exampl:

S:He says, “That IV site in my right arm sure hurts today.”

O:His oral temperature is 98.8, R=18, P=80, BP 110/80

A:I don't know

P:I don't know

I:I don't know

E:I don't know

I just need somebody can write this correct SOAPIE,and then I can see this correct SOAPIE. Everybody understand? Just use I show the Scenario write a correct example of the SOAPIE.

allnurses Guide · Nov 23, 2008

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

PiscesY · Nov 23, 2008

Thank you answer me.

I know what is the mean of SOAPIE,but I just want you can help me finish my SOAPIE. It mean is read my Scenario, make S,O,A,P,I,E to me.I just want see if you write this SOAPIE,what is your writing?

Daytonite, BSN, RN · Nov 23, 2008

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:

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

now, the soapie note includes the following information:

s (subjective data)

- chief complaint or other information the patient or family members tell you.

o (objective data)

- factual, measurable data, such as observable signs and symptoms, vital signs, or test values.

a (assessment data)

- conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses.

p (plan)

- strategy for relieving the patient's problems, including short- and long-term actions.

i (interventions)

- measures you've taken to achieve expected outcomes.

e (evaluation)

- analysis of the effectiveness of your interventions. based on outcomes you determined in the plan of care.

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. . .

problem #1: ineffective tissue perfusion, cerebral and gastrointestinal r/t impaired transport of oxygen and vasoconstriction of peripheral vessels

s: patient stated, "i'm still not very hungry, my stomach gets upset with heavy foods like fried eggs and pancakes."

o: facial skin is warm, pink, and dry. ate only a small amount of breakfast.

a: has good perfusion of peripheral tissues; perfusion to gi tissues may not have returned to normal

p: continue to monitor circulation status.

i: contact kitchen and instruct them to send bland foods and nothing that is fried.

e: n/a at this time.

problem #2: ineffective airway clearance r/t excessive secretions

o: breathing is regular. respiratory rate is 18. lung fields have normal-sounding airflow on both sides of the back and front of his chest.

a: airway is clear

p: continue to encourage patient to deep breath and cough q1h.

e: free of dyspnea.

problem #3: deficient fluid volume r/t fluid loses

s: "that iv site in my right arm sure hurts today."

o: voiding clear, straw-colored urine. skin around the iv catheter is red and tender to touch. the iv is dripping at an 80cc per hour rate according to the meter in the iv ac iv pump.

a: hydrated. phlebitis of iv site.

p: change iv site.

i: at ____ iv was d/c'd from right arm and restarted in left hand with a #20g catheter. iv fluids restarted at 80cc/hour. patient tolerated the procedure well.

e: fluid volume is being maintained.

problem #4: hyperthermia r/t inflammation of meninges and lung

o: oral temperature is 98.8.

a: fever is within normal range.

p: provide antipyretics and cooling measures if needed.

i: none at this time.

e: afebrile.

problem #5: impaired mobility r/t inflammation and tension on spinal nerve roots

o: assisted by myself to the bathroom to urinate.

a: needs one person assist to ambulate safely.

p: continue to provide ambulatory assistance.

e: has not yet verbalized a feeling of increased strength.

problem #6: acute pain r/t inflammation of meninges and nuchal rigidity

s: mr. reyes says that he no longer has a headache or neck ache.

a: no pain.

p: continue to monitor for headache and neck pain.

e: patient reports no pain.

problem #7: disturbed sensory perception, visual r/t altered sensory perception

s: mr. reyes says that he no longer has photophobia.

a: no visual disturbances.

p: continue to monitor for visual disturbances.

e: patient reports no photophobia.