Soapie 1

S- “ang sakit nurse, ano po pwede kong gawin” as verbalized by the client.
O- Restlessness
- Facial Grimaces
- Vital signs taken: T- 36.5 ⸰C, BP: 100/72 mmHg, RR: 24 cpm, HR: 96 bpm, SPO2:
94%
A- Acute pain
P- After 2 hours of Nursing Intervention, the client will demonstrate the use of relaxation
skills and diversional activities appropriate to the situation.
I- 7:30 am: Monitored the patient’s vital signs, especially noting for parameters of
respiratory function such as depth, rhythm, and rate.
- 7:45 am: Positioned the patient in a Semi-Fowler’s position.
- 8:00 am: Taught the patient how to support the head and the neck during
movements, placing the hands behind the neck and slowly moving when needed.
- 8:30 administered prescribed analgesic and other medications for pain and/or
swelling.
E- The client was able to demonstrate the use of relaxation skills and diversional
activities appropriate to the situation.

Soapie 2
S- “Medyo nahihirapan akong magsalita kasi parang walang boses na lumalabas at
parang hangin lang ang lumalabas” as verbalized by the patient
O- Speaks slowly
- Mostly uses gestures
A- Impaired verbal communication
P- Client will establish a method of communication in which needs can be understood
and expressed and demonstrate congruent nonverbal communication.
I- . 7:00 AM: Established a relationship with the client, listening carefully and attending
to the client’s verbal/nonverbal expressions.
7:20 AM: Provided alternative methods of communication like slate board and picture
board.
8:00 AM: Visited patient
8:30 AM: Post notice of the patient’s voice limitations at central station and answer call
bell promptly.
8:40 am: Maintained a quiet environment.
E- Client established a method of communication in which needs can be understood
and expressed and demonstrated congruent nonverbal communication.

SOAPIE 3
S- N/A
O- Vital signs as follows: BP: 100/70, CR:87, RR:18, T: 36.6
A- Risk for ineffective airway clearance
P- Client will maintain a patent airway, with aspiration prevented.
I- 7:00 AM: Monitored respiratory rate, depth, and work of breathing.
7:20 AM: Auscultated breath sounds, noting the presence of rhonchi.
7:30 AM: Assessed for dyspnea, stridor, “crowing,” and cyanosis.
7:40: Cautioned patient to avoid bending neck; support head with pillows.
8:00 AM: Assisted with repositioning, deep breathing exercises, and/or coughing as
indicated.
10:00 AM: Suctioned mouth and trachea as indicated, noting color and characteristics of
sputum.
11:00 AM: Checked dressing frequently, especially the posterior portion.
1:00 PM: Provided steam inhalation and humidified the room air.
E- Client maintained a patent airway, with aspiration prevented.