VNS Homework help needed

Nurses General Nursing

Published

ok, well i'm just a student who just started learning how to document. It's only been 2 wks into this document thingy. Just 2 lectures on it and i'm lost on how to do it. I need to know realllly bad, cause i start clinical with my class this friday. Im gonna be dealing with patients and if i don't get this down, i might kill someone! >.

I need help on documenting S.O.A.P.I.E on a client who just had A Cerebrovascular Accident(stroke) and Diarrhea at the same time. Please help me, it's due on this thursday!:chair:

Up Vote Up Vote ×
Specializes in Education, Acute, Med/Surg, Tele, etc.

Break down the accronym...S=subjective, O=objective, A=assessment, P=Plan (of action) and I don't know what the I..E..means since I only learned and used SOAP.

In cases like this, I state a quote that person said or hand movements or if they are able to do any of that...that is my subjective. For a CVA I have heard lots of quotes "my head hurts", "I feel funny", "My right arm is numb", "I feel faint", "I have never felt like this before (very important quote actually!)...etc...

Objectively I look for signs and document it exactly how I see it! Arrived in patients room to find them on the commode having a large tan runny stool. Pt is looking pale, diaphoretic (sweaty), and appears uncomfortable by facial grimice and trying to move R upper extremity repeatedly.

Then my assessment: Pt has noteable right sided droop to the eye and lip, slurred speech, R pronator drift, and unable to grip with R hand, R leg slow/weak dorsal/plantar flexion compaired to the right. VS as follows....Patient has no history of stroke, however is taking coumadin for previous cardiac issues, and is on lisinopril for high blood pressure (HTN)...ect. Patient is a DNR (or not...good place to put that here!). Also mention bowl probelm here as well as any other probelms you encounter.

Plan: I called 9-11 (or stroke/code team in hospital) and initiated ABC's to assure patient airway and continued assessment until paramedics arrived. Reassured patient that help was on the way, and stayed with the patient till they left with paramedics. Called family to inform them of the situation and where patient was being sent. Notified MD via call (or fax or whatever). Will fax over medication sheets to ER, and report to ER RN prn.

Hope that was helpful to you :)

Up Vote Up Vote ×
Break down the accronym...S=subjective, O=objective, A=assessment, P=Plan (of action) and I don't know what the I..E..means since I only learned and used SOAP.

In cases like this, I state a quote that person said or hand movements or if they are able to do any of that...that is my subjective. For a CVA I have heard lots of quotes "my head hurts", "I feel funny", "My right arm is numb", "I feel faint", "I have never felt like this before (very important quote actually!)...etc...

Objectively I look for signs and document it exactly how I see it! Arrived in patients room to find them on the commode having a large tan runny stool. Pt is looking pale, diaphoretic (sweaty), and appears uncomfortable by facial grimice and trying to move R upper extremity repeatedly.

Then my assessment: Pt has noteable right sided droop to the eye and lip, slurred speech, R pronator drift, and unable to grip with R hand, R leg slow/weak dorsal/plantar flexion compaired to the right. VS as follows....Patient has no history of stroke, however is taking coumadin for previous cardiac issues, and is on lisinopril for high blood pressure (HTN)...ect. Patient is a DNR (or not...good place to put that here!). Also mention bowl probelm here as well as any other probelms you encounter.

Plan: I called 9-11 (or stroke/code team in hospital) and initiated ABC's to assure patient airway and continued assessment until paramedics arrived. Reassured patient that help was on the way, and stayed with the patient till they left with paramedics. Called family to inform them of the situation and where patient was being sent. Notified MD via call (or fax or whatever). Will fax over medication sheets to ER, and report to ER RN prn.

Hope that was helpful to you :)

thank you veryyyy much. big help.

Up Vote Up Vote ×

yeah, So what does the I.E. stand for? Never heard that one before?

"Be kinder than necessary, for everyone you meet is fighting some kind of battle."

Up Vote Up Vote ×

I-Intervention

E-Evaluation

:imbar

Up Vote Up Vote ×
Specializes in Education, Acute, Med/Surg, Tele, etc.

LOL, well my intervention was in my plan, and the evaluation would either be no change, or done in hospital...LOL!

Up Vote Up Vote ×
LOL, well my intervention was in my plan, and the evaluation would either be no change, or done in hospital...LOL!

Hahaha, Yes it was in there. Everyone has a different method i guess.:rotfl:

Up Vote Up Vote ×
+ Add a Comment