soapier format or sbar

Here.I.Stand, BSN, RN · Sep 18, 2014

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?

Esme12, ASN, BSN, RN · Sep 18, 2014

how does this apply to SOAP or Sbar?

beckyboo1, BSN, RN · Sep 18, 2014

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.

toomuchbaloney · Sep 19, 2014

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

rma1965 · Sep 26, 2014

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

Esme12, ASN, BSN, RN · Sep 26, 2014

Subjective-This is what the patient is saying about how they're feeling.

Objective-This is what you are observing is happening.

Assessment-This is your assessment-usually all the head to toe stuff in addition to your observations of the patient's problem.

Plan-This is what you plan to do for that patient r/t the problem and overall care, and the goals for the patient.

Implement-This is what you've done.

Evaluation-This is whether the care so far has been effective in helping the patient reach the goals

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.

nausea related to anesthetic

s: patient states, "i feel nauseated."

o: patient vomited 100ml of clear fluid at 2255.

a: patient is nauseated.

p: monitor nausea and give antiemetic as necessary.

i: patient given compazine 1mg iv at 2300.

e: patient states she's no longer nauseated at 2335.

So looking at your information....

78 year old patient medical diagnosisaspiration pneumonia in severe distress abnormal 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 presented reddened area on 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

Now tell me how you would use this information to write a nursing note. Lets start there.