JMJ Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences
Nursing Department

SOAPIE CHARTING
Patient’s Name: Patient R Age:28 years old Sex: Male
Chief Complaint: ___________________________ Diagnosis: Alcohol Withdrawal
Date Admitted: June 8, 2021 at 11:30 AM

Date/ Time/ Shift June 8, 2021, 1:00 PM

Problem & Nursing

Diagnosis

“I’m anxious right now. I seem to feel that the world is ending. I need
the cure, that $4-dollar worth of cure just to make me feel relaxed.” As
S
verbalized.

(+) Anxiety, (+) Profuse Sweating, Pulse rate of 136 bpm, (+)
Vomiting, (+) Hand tremors,

A Anxiety r/t cessation of alcohol use

At the end of 3 hours nursing intervention, the patient will be able to

feel relaxed. Specifically: Display a normal vital sign especially PR in
between the range of 60-100bmp. Verbalize absence of or decrease
P in subjective distress. Have posture, facial expressions, gestures, and
activity levels that reflect decreased distress such as calm and stable.
 Established a trusting relationship by frequent contact and being non-
judgmental; Project an accepting attitude; Used empathy to encourage
patient to interpret the anxiety symptoms as normal; if irrational
I thoughts were present, offered patient an accurate information and
encourage him to talk about the meaning of the events contributing to
anxiety; Encouraged to use positive self-talk; Explained all activities,
procedures, and issues that involve the patient. Used calm, slow
speech and validate patient’s understanding. Encouraged deep
breathing exercises; Maintained quiet and calm surroundings. Used
guided imagery to decrease anxiety; Provided with a means to listen
to music of their own choice. Used therapeutic touch and healing
touch techniques. Administered diazepam (Valium) 5mg q8 as
ordered.
After 3 hours of nursing intervention, the patient was able to display
normal PR of 80 bpm; He verbalized that he feels better; Have a calm
and stable posture which reflects decreased distress. (-) Anxiety, (-)
E Profuse Sweating, (-) Hand tremors, (+) nauseated