SOAPIE problem HELP :(

Whispera, MSN, RN · Jul 16, 2011

"ate 40 percent of dinner with help of staff"

"unable to wash hands by herself"

BonewaxRN · Jul 16, 2011

High risk of infection: unable to clean self after toileting d/t immobility (which would put her at risk for UTIs), decreased skin integrity aeb dryness and poor turgor.

Luka91 · Jul 16, 2011

thank you very much for your replies. so, actually information like "unable to bring food to her mouth" is actually objective?

we really had profesors problems on college during "proces of nursing" so really noone showed us proper way to solve SOAPIE.

thank you so much

Whispera, MSN, RN · Jul 16, 2011

Unable to bring food to her mouth is not really objective. I think it's subjective because how do you know she can't? Maybe she just doesn't want to. It could be the S part of the note. O = objective, or something you can see, hear, smell, taste, touch. So, anything you observe the patient doing fits into the O part of the nursing note. Objective would be, "patient did not attempt to bring spoon to mouth even with food placed on the spoon for her, during dinner."

I think of it this way:

S = subjective or what it seems is going on, but you haven't observed it

O = objective or observed

So, in a note for the S part you might say "patient seems uninterested in eating," but the O part might say, "patient would not open mouth when aide tried to feed her at dinner," or "patient was able to eat 40% of dinner with staff help," or even "patient stated she does not want to eat dinner." The O is data that supports the S. Both flow from the nursing diagnosis.

A = assessment of the overall picture, using both S and O

P = plan or what should staff do about it, generally

I = the specific interventions to fulfill the plan

E = evaluation or how would staff know the plan was completed

A lot of mumbo-jumbo? yes. It's intended to get you to sort through what you observe and what you need to do about it. I think there are easier ways of charting doing it!

Luka91 · Jul 16, 2011

oh....yes, lot of mumbo-jumbo indeed when you look at first, but thank you for getting me some stuff sorted out. so i'll do it like this:

s:weakness, dysphagia

o:was able to eat whole meal with help by nurse

and then i come to PIE yadayadayada and it's done.

i'll try out, with that

actually until now i thought that by objective only measureable stuff comes by. i tried to find some samples of SOAPIEs but every i found had only such stuff as temperature or decubitus and pain scales and such stuff. it seemed like people really run away from any other diagnoses.

thank you very much for this post, you showed me totally different perpective on this, actually simple, but i still can't deny that i was blind in front of such thing

thank you again for helping out, all of you :)

Whispera, MSN, RN · Jul 16, 2011

Objective means you can observe it. You observe what the patient says, through hearing it, right? Therefore, a quote of what the patient says is objective. However, more specific things are better to use in the O part of the SOAPIE, such as patient won't open mouth, patient does not speak, patient ate 20% of dinner, patient shook head negatively, when asked to sit up.

I hope this all helps. It's a different way of thinking that's way too detailed, in my opinion, but since it's what medical professionals use, we need to learn to do it. Doctors often use SOAPIEs or SOAPs or just APIs or APIEs.

Personally, I prefer DIRPs (Date, Interventions, Response of patient, and Plan of what to do next.). But I digress.

Try to think of it as a game, where you have to find all the pieces...

honeykrown, MSN, NP · Jul 17, 2011

unable to bring food to her mouth can be objective. If you try to get her to eat and she tries several times to lift the spoon but cant. You observed her doing it.