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Subjective, Objective, Analysis, Plan, Implentation, Evaluation

1) The patient, Ron Brown, a 71-year-old man with type 1 diabetes, reported a pain level of 6/10 in his right foot heel where he had an ulcer. On examination, the ulcer had moderate drainage with pus and the patient limped when walking. 2) The nurse relieved the patient's pain by administering Tylenol #3, and changed the dressing. The pain level reduced to 1/10 after medication. 3) The second scenario describes an 89-year-old postoperative patient, Ada Green, who reported pain and difficulty breathing. Her vital signs and dressings were assessed, pain medication was instructed, and breathing techniques encouraged. The patient later reported pain relief

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Danna Kim Auxtero
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216 views3 pages

Subjective, Objective, Analysis, Plan, Implentation, Evaluation

1) The patient, Ron Brown, a 71-year-old man with type 1 diabetes, reported a pain level of 6/10 in his right foot heel where he had an ulcer. On examination, the ulcer had moderate drainage with pus and the patient limped when walking. 2) The nurse relieved the patient's pain by administering Tylenol #3, and changed the dressing. The pain level reduced to 1/10 after medication. 3) The second scenario describes an 89-year-old postoperative patient, Ada Green, who reported pain and difficulty breathing. Her vital signs and dressings were assessed, pain medication was instructed, and breathing techniques encouraged. The patient later reported pain relief

Uploaded by

Danna Kim Auxtero
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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.

Auxtero, Danna Kim A


BSN- 1F

SOAPIE DOCUMENTATION
Subjective, Objective, Analysis, Plan, Implentation, Evaluation

Scenario #1

Name of patient: Ron Brown


Age: 71-year-old
Case: Type 1 diabetes with ulcer on right foot heel

DATE TIME PROBLEM NOTE


0800 Pain regarding - S: - ''I have pain
where the ulcer is ''where the ulcer is
Pain scale as 6 -
out of 10

O: - Facial grimacing
Patient limped -
on his right foot
when he walked to
the bathroom
Moderate -
amount of fresh,
watery bloody
drainage with small
amount of green-
yellow pus

A: - Acute pain
related to right foot
ulcer

P: - Relieve pain by
administering pain
medication
Dressing should -
be changed as often
0830 as needed

I: - Administered
pain medication
0950 (Tylenol #3-2 tablets)
--- Diane, RN
Dressing -
removed
Diane, RN---
Redressed with -
an adaptive dressing,
2-4x4 gauze and 1/2
abdominal pads
Diane, RN ---

E: - The intensity of
the pain was
relieved, as stated
patient; from 6/10 to
1/10 after pain
medication was
given
Diane, RN ----
The patient did -
not complain any
discomfort during
the dressing changed
and handled it well
Diane, RN ----

FDAR DOCUMENTATION
Focus, Data, Action, Response

Scenario #2
Name of Patient: Ada Green
Age: 89-year-old

DATE TIME FOCUS PROGRESS NOTE


October 12 0950 Post-operative D: - Patient was seen
abdominal pain in her chair looking
anxious and
unkempt
Patient stated ''I -
am in pain'' and ''I
cant seem to
''breathe
Dressing were in -
disarray, and there
was a distinct fecal
odor and the patient
was perspiring
profusely

Temperature 38 -
degrees Celsius,
pulse 110/minute
and regular, blood
pressure 100/70
mmHg, respiration
28 breaths/minute
and mildly labored

A: - Vital signs were


taken
Assess and -
.redress the wound
Encourage -
breathing technique
Instruct to take -
medications as
needed

R: Reports pain
relieved. --- Janie, RN

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