ACTUAL SOAPIEs

S–O

O – received patient lying on bed; conscious and coherent; oriented to time, place, and
persons; with an ongoing IV fluid of D5W 500cc @ 50cc level, infusing well on the left
hand and regulated KVO; afebrile; with good skin turgor; with pinkish palpebral
conjunctiva; with moist oral mucous membranes; with capillary refill less than 2 seconds;
absence of DOB; absence of chest pain; with initial VS taken and recorded as follows: T:
35.3; P: 66; R: 18; BP: 100/60

A – Decreased cardiac output related to altered stroke volume (altered afterload:

alterations in blood pressure) and ECG changes

P – after four hours of nursing interventions, patient will display hemodynamic stability
(normal BP)

I – established rapport

- Monitored and recorded VS

- Assessed general condition

- Regulated and monitored IVF as ordered

- Provided AM care

- Kept back dry

- Reviewed diagnostic studies (ECG)

- Encouraged adequate rest periods

- Assisted with performing self-care activities

- Instructed client to limit activities

- Encouraged use of relaxation techniques

- Reinforced low salt, low fat diet

- Encouraged frequent position changes

 - Encouraged to do AROM exercises

- Instructed that he may sit on bed once in a while

- Provided comfort and safety measures

- Emphasized importance of taking medications religiously

- Promoted client safety

- Provided adequate rest periods

- Administered meds as ordered

- Seen on rounds by Dr. X with orders made and carried out:

 Repeat 12 lead ECG with LLII – done

 Follow up 2D echo result – done

 May walk around the bed – instructed

 Continue meds

 Monitor VS

E – goal met AEB patient displayed homodynamic stability

S–O

O – received patient lying on bed; conscious and coherent; oriented to time, place, and
persons; with an ongoing IV fluid of D5W 500cc @ 30cc level, infusing well on the left
hand and regulated KVO; afebrile; with good skin turgor; with pinkish palpebral
conjunctiva; with moist oral mucous membranes; with capillary refill less than 2 seconds;
absence of DOB; absence of chest pain; with initial VS taken and recorded as follows: T:
36.1; P: 72; R: 20; BP: 100/70

A – Decreased cardiac output related to altered stroke volume (altered afterload:

alterations in blood pressure) and ECG changes

P – after four hours of nursing interventions, patient will able to participated in activities
in reduce work load of the heart

I – established rapport

- Monitored and recorded VS

- Assessed general condition

- Above IV fluid consumed and hooked another IV fluid D5W 500cc x KVO
@ 8:30am

- Regulated and monitored IVF as ordered

- Provided AM care

- Stretched bed linens

- Kept back dry

- Encouraged adequate rest periods

- Assisted with performing self-care activities

- Instructed client to limit activities

- Encouraged use of relaxation techniques

- Reinforced low salt, low fat diet

 - Encouraged frequent position changes

- Encouraged to do AROM exercises

- Instructed that he may walk around the bed

- Provided comfort and safety measures

- Emphasized importance of taking medications religiously

- Promoted client safety

- Provided adequate rest periods

- Administered meds as ordered

E – goal met AEB was participated in activities reduce work load of the heart
I. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

Client’s Daily Progress Chart

DAYS N0v Discharge

28-
2010 to Dec 9 2010

NURSING PROBLEMS

1. Activity Intolerance √ √

2. Impaired Skin Integrity √ √

3. Imbalanced Nutrition: Less Than √ √

Body Requirements
√ √
4. Acute Pain

VITAL SIGNS

1. Temperature (0C/axilla) 36.1 35.3 36.3

2. Pulse Rate (beats per minute) 80 62 66

3. Respiratory Rate (breaths per 32 18 18

minute)
160/80 100/60 100/70
4. Blood Pressure (mmHg)

DX’C/Lab Procedures

1. ECG Non-ST Non-ST Segment

Elevation; T-wave
Segme
inversion
nt
Elevati
on; T-
wave
inversio
n

9MEDICAL MANAGEMENT nov 2 30 1 2 3 4 5 6 7 8 9

-28 9
1. IVFs
 2. Oxygen Therapy √ √ √ √ √ √ √

√ √

Meds

1. morphine 0.4cc IV for severe chest

pain
√ √ √ √ √ √ √
√ √ √
2. enoxaparine 4cc SQ q 12 x3days √
√ √ √ √ √ √ √
√ √ √
3. ASA 80 Tab OD √
√ √ √ √ √ √ √
√ √ √
4. clopidogrel 75 mg/tab OD √
√ √ √ √ √ √ √
√ √ √
5. Captopril 25mg tab bid √
√ √ √ √ √ √ √
√ √ √
6. metoprolol 50mg/tab BID √
√ √ √ √ √ √ √
√ √ √
7. Omega 3 tab OD √
√ √ √ √ √ √ √
√ √ √
8. Lactolose 30 cc OD HS √
√ √ √ √ √ √ √
√ √ √
9. Atrovastatin 80 mg tab HS √
√ √ √ √ √ √ √
√ √ √
10. FUROSEMIDE 40 mg q6 √
√ √ √ √ √ √ √
√ √ √
√

DIET

1. Low salt, low fat √ √ √ √ √ √ √ √ √ √ √

Discharge Planning (December 9, 2010)

a. General condition of client upon discharge

The client was in her best condition was she was discharged. There was
absence of chest pain and difficulty of breathing.

Instructions given and explained as follows:

 M - instructed the patient to take the following meds:

>ASA 80mg/tab OD

>Clopidogrel 75mg/tab OD

>Atorvastatin 80mg/tab OD

>Captopril 25mg/tab BID

E – instructed patient to avoid activities requiring exertion

T–

H – instructed patient to:

>elevate lower extremities when lying down

>have adequate rest periods

>limit activities

>do relaxation techniques when indicated

O – instructed patient to return after one week @ OPD @

8am for follow-up check up

D – instructed patient to avoid or limit foods rich in sodium

and fats