SAMPLE CHARTING: S.O.A.P.I.

Patient Name: Mrs. Dorothy

Age: 52 y/old

Subjective:

“sumakit po ang bandang kaliwa ng dibdib ko” as verbalized by the patient.

Objective:

- Facial grimacing
- Restlessness
- Shortness of breath
- Sweating
- Obvious sense of impending doom
- Pain scale: 7/10
Vital signs taken:

- BP: 130/90 mmhg

- PR: 109 bpm
- RR: 26 cpm1
- Temp: 37.8 ℃

LAB RESULT:

- ECG result changes ST elevation in leads 1, AVL, V2, V3, V4, V5 and V6

- Increased cholesterol and triglyceride level of 230 mg/dL

- Cardiac enzyme slightly elevated initially and rose drastically after 6 hrs of 0.53 ng/ml.

Assessment:

Acute (chest pain) related to myocardial infarction.

Planning:

After 2 hours of nursing intervention, the client will have improved comfort in chest, as evidence by:

- Decrease pain scale on chest pain from 7/10

- Able to rest and displays reduced tension

Interventions:
Independent:

1. Assess characteristics of chest pain, by using PQRST and document findings in nurse’s notes
2. Obtain history of previous cardiac pain and familial history of cardiac problems.
3. Assess vital signs such as RR, BP and PR
4. Maintain bedrest, with a comfortable position (semi-fowler’s position) and maintain relaxing
environment.

Dependent:

1. Obtain a 12- lead ECG tracing in each time chest pain occurs as ordered
2. Administer Morphine Sulfate 5 ml IV stat and Ranitidine 50 mg/ ampule IV q 8 hours as
prescribed.
3. Administer oxygen as ordered

Collaborative:

1. Give proper education regarding the diet of the patient as ordered by the Nutritionist
2. Request of lab test in the laboratory

Intervention:

Independent:

1. Assessed characteristics of chest pain, by using PQRST and document findings in nurse’s notes
2. Obtained history of previous cardiac pain and familial history of cardiac problems.
3. Assessed vital signs such as RR, BP and PR
4. Maintained bedrest, with a comfortable position (semi-fowler’s position) and maintained
relaxing environment.

Dependent:

1. Obtained a 12- lead ECG tracing in each time chest pain occurs as ordered
2. Administered Morphine Sulfate 5 ml IV stat and Ranitidine 50 mg/ ampule IV q 8 hours as
prescribed.
3. Administered oxygen as ordered

Collaborative:

1. Gave proper education regarding the diet of the patient as ordered by the Nutritionist
2. Requested of lab test in the laboratory

Evaluation:

After 2 hours of nursing intervention, the client achieved improved comfort in chest, as evidenced by:

- Decreased pain scale on chest pain from 7/10 to 4/10

Was able to rest and displays reduced tension