SOAPIE CHARTING #1

Name: Mr. Alcot

Age: 68-years-old
Gender: Male
Date Admitted: July 16, 2021 (8:00 am)
CC: Cough and fever for four days
Diagnosis: Pneumonia

S: “Nahihirapan akong huminga dahil sa ubo at plema” as verbalized

O:
 Presence of sputum noted (thick and yellow with streaks of blood)
 Pain in right chest that intensifies with inspiration
 Productive cough
 Difficulty of breathing
 Auscultation reveals bilateral diminished vesicular breath sounds
 Bronchial breath sounds, rhonchi and late inspiratory crackles (are heard) in the
area of the right mid-anterior and right mid-lateral lung fields
 Respiratory rate taken:
RR: 24 cpm
A – Ineffective airway clearance related to increased sputum production as evidenced by
productive cough with presence of thick and yellow sputum streaks of blood
P- Within 6 to 8 hours of rendering appropriate intervention, will be able to expectorate
phlegm
I-
• 8:00 am- Elevated the head of the bed
• Assisted change position every 2 hours
• Encouraged liberal fluid intake
• Instructed to take warm liquids instead of cold ones
• Encouraged and demonstrated deep breathing and huff coughing technique
• Encouraged patient to increase intake of nutritious food like fruits and vegetables rich in
vitamin C
• Facilitated quiet environment and adequate rest
• 8:00am -Performed suctioning as ordered
• Administered oxygen therapy as ordered
E-
• RR: 19 cpm
• Able to expectorate phlegm within a shift
• Able to take rest and nap at times
• Endorsed
SOAPIE CHARTING #2

Name: Mr. Alcot

Age: 68-years-old
Gender: Male
Date Admitted: July 16, 2021 (8:00 am)
CC: Cough and fever for four days
Diagnosis: Pneumonia

S: “Mainit at masama pakiramdam ko”- as verbalized

O:
 Fever (temperature taken:
102.6 F)
 Shaking
 Chills
 Malaise
 Warm to touch
A- Hyperthermia related to infection process as evidenced by temperature of 102.6 F
P- Within 1 hour of providing appropriate nursing intervention, the temperature will
decrease from 102.6 F to 98.9 F
I-
• 8:00am - Provided tepid sponge bath
• Provided cool circulating air using a fan.
• Placed a cool cloth or cooling patches on the client’s forehead
• Positioned the patient in a comfortable position and elevate the head of the patient
• Facilitated bed rest
• Assisted patient in changing into dry clothing.
• 8:00am- Administered medications as prescribed
E-
• T: 98.9 F
• Able to take rest and nap at times
• Endorsed
SOAPIE CHARTING #3

Name: Mr. Alcot

Age: 68-years-old
Gender: Male
Date Admitted: July 16, 2021 (8:00 am)
CC: Cough and fever for four days
Diagnosis: Pneumonia

S: “Masakit dibdib ko dahil hindi ako makahinga”- as verbalized

O:
 Guarding Behavior (holding his right chest using left arm)
 Pain in right chest that intensifies with inspiration
 Cough Continuously
 Apical heart rate taken:
112 bpm
 Respiratory rate taken:
24 cpm
A- Acute pain related to persistent cough as evidenced by pain in right chest
P- Within 1-4 hour of providing appropriate nursing intervention, verbalize relief/ control
of pain
I-
•8:00 am- Provided comfort measures: back rubs, position changes, quite music, massage.
Encouraged use of relaxation and/or breathing exercises.
• Positioned the patient in a comfortable position and elevated the head of the patient
• Offered frequent oral hygiene
• Instructed and assisted patient in chest splinting techniques during coughing episodes
• 8:00 am- Administered antitussives as indicated. Do not suppress a productive cough;
moderate amounts of analgesics are used to relieve pleuritic pain.
• Administered analgesics as prescribed. Encourage patient to take analgesics before
discomfort becomes severe
E-
• RR: 20 cpm
• Verbalized relief/ control pain within a shift
• Able to take rest and nap at times
• Endorsed