Patient Progress Notes

SOAPIE
Updates in Nursing Diagnoses
(2015-2017)
 Documentation
Documentation is any written or
electronically generated information
regarding a client that describes the
care or service provided to that client.
Through documentation, nurses
communicate their observations,
decisions, actions and outcomes of
these actions for clients.
Documentation is an accurate account
of what occurred and when it occurred.
 Reasons for
Documentation
To facilitate communication
communicates to other nurses and care
providers
decreases the potential for
miscommunication and errors
 Reasons for
Documentation
To promote good nursing care
encourages nurses to assess client
progress and determine which
interventions are effective and which
are ineffective
source of data for making decisions
about funding and resource
management as well as facilitating
nursing research
 Reasons for
Documentation
To meet professional and legal
standards
nurse has applied nursing knowledge,
skills and judgment according to
professional standards
NANDA-Based Diagnosis
North American Nursing Diagnosis
Association

Nursing diagnoses communicate the

professional judgments that nurses
make every day to their clients
Nursing diagnoses define what we know
- they are our words.
The Nursing Cycle
 WHATS NEW?
Updates, changes, and
revision in Health Promotion
and Risk Diagnoses
A standardization of diagnostic
indicator terms (defining
characteristics, related
factors, and risk factors)
 WHATS NEW?
16 new NANDA Nursing Diagnoses
Risk for Ineffective Activity Planning
Risk for Adverse Reaction to Iodinated
Contrast Media
Risk for Allergy Response
Insufficient Breast Milk
Ineffective Childbearing Process
Risk for Ineffective Child Bearing
Process
Risk for Dry Eye
 WHATS NEW?
Deficient Community Health
Ineffective Impulse Control
Risk for Neonatal Jaundice
Risk for Disturbed Personal Identity
Ineffective Relationship
Risk for Ineffective Relationship
Risk for Chronic Low Self-Esteem
Risk for Thermal Injury
Risk for Ineffective Peripheral Tissue
Perfusion
 DOCUMENTATION
Communication tool

It should be accurate,
effective, efficient, concise,
organized

Do the ADPIE
 ACCURACY
Communication main source of
information
Legal protection shows standards of
nursing care has been met
Healthcare evaluation patients
response to care rendered
Research and education
Performance improvement
Compliance with nurse practice acts
Subjective
Objective
Assessment
Planning
Interventions
Evaluation
 Rules in Documentation
1. Complete, concise, accurate
2. Objective
3. Prompt
4. When adding late entry, label it as such
5. Legible
6. wrong entry emscastillo date/time
7. Write N/A if appropriate
8. Sign each entry
 PRINCIPLES
1.Assess! Assess!
Asess!
Back bone of
documentation
Be aware of the
medical diagnosis of
your patient
Example: Congestive
 PRINCIPLES
2.Know what your
doing
Do it systematically and
comprehensively

3.NANDA out!
Dont make book-based
interventions and
 PRINCIPLES
4.Stop Using Alteration
in Comfort

It should be impaired
comfort.
Dont over-use.
 PRINCIPLES
5.Choose a better
nursing diagnosis

- Prioritize your diagnosis

- Nursing diagnosis should
be strongly supported by
your assessment cue
 PRINCIPLES
6.Plan SMART

Make it short and precise

(max of 10 words)
will be able to
 PRINCIPLES
7.INTERVENE
Document what is done
Independent, dependent,
collaborative
It should be on past tense
Administered
Document any suggestions
Health teaching!!!
 PRINCIPLES
8.Evaluate your
interventions

Is it goal met, partially

met, not met?
Assess!!!
LETS DIFFERENTIATE
Ineffective Airway Clearance
Vs.
Impaired Gas Exchange
Vs.
Ineffective Breathing Pattern
LETS DIFFERENTIATE
Knowledge Deficit
Vs.
Readiness for Enhance
Knowledge
 DOMAIN
Health Promotion
Nutrition
Elimination and Exchange
Activity/ Rest
Perception/ Cognition
Self-Perception
Role Relationships
Sexuality
 SAMPLE SOAPIE
Received patient awake on bed
With ongoing PNSS 1 liter to run for 8 hours at
650mL level, inserted to left cephalic vein using
gauge 22
s/p open cholecystectomy (date)
On NPO
With dry and intact dressing
With ongoing #1 PRBC 240mL x 4 hours at
150mL level
S C.O.L.D.S.P.A / P.Q.R.S.T
 SAMPLE SOAPIE
A acute pain
P attain pain score of 2/10 or better after
2 hours
I advised to do relaxation technique
(watching television)
- demonstrated deep breathing exercise
- instructed to breath deeply at least 10
times in a minute for 10 minutes
- encouraged and assisted in ambulation
 SAMPLE SOAPIE

I placed and assisted in changing

position (semi-fowlers)
- monitored for presence of flatus
- instructed to maintain on fasting
until further instructions
E pain score 2/10, goal met

Emerson Castillo, RN
CHALLENGE YOURSELF
S
O
A - RISK FOR FALL
P
I
E
CHALLENGE YOURSELF
S
O
A - HYPERTHERMIA
P
I
E
WORKSHOP
 Case: Mrs Sunninghill is a 90 year old lady,
admitted with an oozing abdominal wound with
underlying odour, with a history of 8 days.
Impression: RLQ swelling r/o abscess/tumour.
Lives at home by herself, has meals on wheels and
home help with cleaning, independent with
mobility and hygiene cares. Patient has a daughter
and son who live out of town. Daughter has power
of attorney, has noticed her mother is slowly
deteriorating physically since January. She has
spoken with her mum and GP about this situation
and the need for residential care input no
referrals made to date in the community.
Medical history: Appendectomy at age of 13,
Hysterectomy, Hypertension, Subclinical
hypothyroidism
 Hospital journey: patient has been in hospital for
4 days, during this time family and patient have
been actively involved in plan of care and decision
making. A diagnosis of a bowel tumor has been
confirmed, the patient and family do not want
surgical input. The oozing abdominal wound has
been confirmed as a fistula, fecal matter draining
into an ostomy appliance. Appliance keeps leaking
causing excoriation to surrounding skin, Stomal
therapy. CNS has been involved, currently trailing a
different appliance. Patient became unconscious
during shower, medical emergency coded result
vasovagal.

Plan: No surgical input. For palliative care in a

residential care facility. Referrals to be made to
Physio, OT, SW and Palliative Care.