UNIT 5

EVALUATION

Pre task
S-O-A-P (Subjective, Objective, Assessment, Planning)
SOAP Notes
Patient Name : Ahmad
Record No. : 585-1121-337
Subjective : Pt said that he feels tight on his chest
Objective : RR 24, Wheezing, SOB, abdominal exertion.
Assessment : Inefective Breathing pattern r/t asthma.
Plan : 1. Give pt high fowler potition.
2. Administer meds via nebulizer.

Find the expressions or abbreviations in the note which mean the following!
1. Medicine or medication.
2. Patient
3. Related to
4. Short breath
5. His abdomen is working hard because he is having problem breathing.
6. Give
7. Respiratory rate.
8. A piece of equipment that administers medications that the patient breaths in.
5.1 EVALUATION
Evaluation is to collect data related to outcomes, compare data with outcome, rel
ate nursing action to client goals or outcomes. Draw conclusion about problems s
tatus (continue, modify or terminate the client care plan).
Example:
The evaluation notes for Ineffective airway clearance related to viscous secret
ion diagnosis:
S = She said that she has effective cough, dyspnoea (-)
O = Sound of breathing; Ronchi (+/+),
Viscous secret changed to liquid secretion
Vital sign:
RR = 22 x/minute
HR = 88 x/minute
A = Effective airway but still possible caused airway disorder (because the infection still
happen)
P = plan of care:
a. Maintain the position; fowler.
b. Maintain the effective cough and deep breath.
c. Give O2 and nebulization (if needed).
d. Suggest tp drink much warm water.
e. Monitor the vital sign.

Task 1

Complete the text with the words in the box and summarise each definition of SO
AP!

Documents Help Measure Summary

Symptoms Treat

SOAP notes are _____Documents____________ 1 that nurses use to rec

ord information about patients. A SOAP note has four parts – Subjectiv
e, Objective, Assessment and Plan. The subjective is what the patient sa
ys about his or her problem. It is the ________Summary____2 the patien
t (or the patient’s family) describes. The objective is what the nurse sees
or observers at the time. It is the symptom that the nurse can see, feel, he
ar, touch and _______Measure_______3 . The assessment is the nurse’s
_______Help_______4 of what the patient’s immediate medical problem
are. The plan is what the nurse plans to do to _________Treat ________
5
the patient’s symptoms and _____Symptoms____________6 with the p
 roblem.

5.2 Nursing abbreviations

Task 2
Pair work
Look at the SOAP notes for the two patients below and note the nursing abbreviat
ions you may find!

Patient Name, Mrs. X Patient Name, Mr. Y

Record No. 987 – PPK Record No. 556 – ULL

S: Client said that she has been ov
erweighed since the birth of her
twin daughters in 2001 and I sh
e get frustrated trying to diet. H
er 25 – year reunion is next yea
r and she really like to lose som
e weight. NKDA, NKA.
O Wt = 95kg, Ht, 1,6m,
: IBW = 115 kg, Chol = 225,
BP = 120/75.
Obese at 183% IBW, hyperchol
A : esterolemia.
Long term goal: change lifestyl
P : e habits to lose at least 27 kg ov
er a 10 – month period.
Short term goal: 1) to begin a 1
500 calorie diet food portions,
2) keep a daily food and mood r
ecord to review next session, 3)
follow up in one week.
S: Client said that he has had pa
in in his right knee for four m
onths, it’s worse when he wa
lks or does any exercise. NK
O: DA.
Wt = 69 kg, Ht = 1, 67 m,
Normal ROM both knees, no
A: redness or swelling.
Possible Osteoartritis r/o rhe
P: umatoid arthritis.
1) Blood work – see for reom
atoid factor.
2) X – Ray of PA and lateral
knee
3) Ibuprofen 400 mg t.id. p.o
4) Recheck in 3 months.

IBW = Ideal body weight mg = Miligram

Chol = Cholesterol t.i.d. = Three Times a Day
ROM = Range of Motion p.o = By mouth / Per Oral
R/O = IAC =
PA = Patologi anatomi
NKDA = Non-Ketotic Diabetic b.i.d = Twice a Day bilat
Acidosis Bilateral
ABC = ……..
NKA = No Known Allergies ……..
BS = Bowel Sounds IBP =
UA = Urinalysis
R = O2 = Oxygen
L = …….. p.r.n. = (pro re nata) AS
NEEDED
hr = Heart Rate