Lim, Moonyeen D.

Nursing Care Note

SOAPIE Method
 Subjective Data;
Her daughter Emelda states that her Mom has difficulty sleeping for the past 2 weeks , and has
stopped engaging in all social activities, including weekly church services, she also has
anhedonia, She cries frequently, and can be seen staring out into space in the early afternoon.
Mrs. Helen says, “I’m a sick woman, and no one will listen to me! I can’t walk, I’m so weak. My
head hurts, and I never sleep more than 3 hours a night.”

 Objective Data;
Physical assessment finding includes Restlessness, Irritable and abnormally sleepy with
Blood pressure: 160/100mmhg, Pulse Rate: 102bpm, Respiratory Rate: 22cpm and
Body temperature 37.2 degree Celsius.

Assessment /Clinical Judgement

Situational grieving

 Plan
Patient will establish again the normal sleep and exprreses her feelings and emotions
verbally.

 Interventions
Talk with the patient about her feelings and emotion realistically.

Listen to the patient.

Encourage the patient to express her feelings to her daughter.

Instruct the patient the patient guardian to listen to her as well as provide her a support system.

 Evaluation

Patient has difficulty sleeping for the past 2 weeks , and has stopped engaging in all
social activities, including weekly church services, she also has anhedonia, She cries
frequently, and can be seen staring out into space in the early afternoon.
Restlessness, Irritable and abnormally sleepy with Blood pressure: 160/100mmhg, Pulse
Rate: 102bpm, Respiratory Rate: 22cpm and Body temperature 37.2 degree Celsius.