soapier format or sbar

I'm having trouble understanding your question, but I'll try. Are you a student? This kind of sounds like a homework question, so I'm going to make you think a bit. :)

Does D/NS .45% KVO mean for a patient with pneumonia aspiration and been in bed rest since 6 months ago cause of cva.

I'm not sure what you mean by, "Does D/NS .45% KVO" mean... Are you asking what this order means in full words, or what does it mean as in implications for the pt?

there is a reddened area in sacrum and ankles.

Think about why a bedridden pt could get red in the sacrum and ankles. Hint: it has nothing to do with IV fluids.

How does that benefit the patient they having severe distress abnormal lung sounds and plenty secretions accumulation?

How does what benefit the pt--the reddened areas? The IV fluids? Since it's just at KVO, I'm guessing the fluids are there to keep the line patent (open) in between doses of meds and so the nurse isn't continually connecting and disconnecting in between meds.

Or are you asking about the pt possibly getting too much fluid? If so... Well it's KVO--10 or 20 ml per hour. That shouldn't fluid overload an adult, and anyway you'd be flushing the line with NS before and after meds if the KVO was not running. So either way, the pt is going to get those small amounts of IV fluids.

But do you have reason to think the pt is fluid overloaded? Anyone with pneumonia is going to have abnormal lung sounds and secretions, whether they're dehydrated, fluid overloaded, or just right. What are some assessment findings that point specifically to fluid overload (in the pulmonary or circulatory systems), vs. pneumonia?

Shouldnt more be done for the patient like administering cipro 500 ,mg iv q12 hours , prn suction, I&O q4, ntipiretic measures PRN

vital sign taken q4

since current vitals are T 39.8,P105,R32/min,BP 150/90.

Well what antibiotic given depends on what the sputum culture showed. Cipro is broad spectrum so could be an option, but that is up to the MD to decide what antibiotic to use.

For suctioning, sure if the person is awake and not on a ventilator I make sure their oral suction is in their reach so that they can suction independently and not have to wait for someone to answer their call bell.

Yes, I&O and frequent VS are important. What changes could one expect to see with aspiration pneumonia? For example, would you be more concerned about BP that is getting higher or dropping?

By "ntipiretic" do you mean antipyretic--fever control? I like to let low-grade fevers stay because it can help the body fight the infection. 39.8 is very high though! So yes I'd be doing some interventions to control that.

What other indications and assessment can be done?

What body systems do you anticipate could decline with pneumonia? What would concern you if you went into the pt's room and found? What lab values might be important to know? Does the pt appear comfortable or say that she is comfortable? What types of discomfort might you expect with pneumonia?

What other professionals might you want to consult with? This pt has a very recent history of aspiration following a stroke. What bodily function, when abnormal can cause this to happen, and who should evaluate the patient?.....How is the patient's nutritional status? Why is good nutrition important? Hint: this pt has more than the lungs that need healing.....Who can help someone to improve physically so that they don't have to be on bedrest anymore? Six months is a LONG time to be in bed!! Does six months in bed have benefits for anyone? Are there risks associated with long periods in bed?

how does this apply to SOAP or Sbar?

Nothing that I can see from the original post. The author of this post would get better answers if the questions were clearer.

I wondered what the OP had been drinking prior to the post...

this is what we supposed to do because how she explained it to us the first time it was confusing as to what she wanted

she wants us to build a SOAPIE charting for this situation

i have never used that format or know how to am new to this !

78 year old patient medical diagnosis aspiration pneumonia. on severe distress abdominal lung sound and plenty secretions accumulation. T 39.8,P105, R32/min, BP 150/90. Family say patient been in bed rest six months ago as result of CVA. he present reddened area in sacrum and ankles.

physician orders

D/NS .45 % KVO

Cipro 500mg IV q 12 hours

AMinophylline 175mg in D?W5% 50 ml q6hrs to run in 3o min

Solucortef 100mg IV q 8hrs

O2 via nasal canula at 3l,min

PRN suction

NPO during 24 hours then liquid diet through NG/tube

Vital signs q4hrs

I&O q 4 hrs

Antipiretic meaures PRN