Scribd
Upload
137 views2 pages

Soapie Charting: Date/ Time/ Shift

The document contains a SOAPIE chart for a patient named Patient R, a 28 year old male admitted for alcohol withdrawal who was experiencing anxiety, profuse sweating, tachycardia, vomiting, and hand tremors. The nurse implemented interventions including empathetic communication, relaxation techniques, administration of diazepam, and monitoring of vital signs and symptoms. After 3 hours the patient's anxiety and physical symptoms improved and he displayed a normal heart rate and stated feeling better.

Uploaded by

spain michaelis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
137 views2 pages

Soapie Charting: Date/ Time/ Shift

The document contains a SOAPIE chart for a patient named Patient R, a 28 year old male admitted for alcohol withdrawal who was experiencing anxiety, profuse sweating, tachycardia, vomiting, and hand tremors. The nurse implemented interventions including empathetic communication, relaxation techniques, administration of diazepam, and monitoring of vital signs and symptoms. After 3 hours the patient's anxiety and physical symptoms improved and he displayed a normal heart rate and stated feeling better.

Uploaded by

spain michaelis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

JMJ Marist Brothers

Notre Dame of Marbel University


College of Arts and Sciences
Nursing Department

SOAPIE CHARTING
Patient’s Name: Patient R Age:28 years old Sex: Male
Chief Complaint: ___________________________ Diagnosis: Alcohol Withdrawal
Date Admitted: June 8, 2021 at 11:30 AM

Date/ Time/ Shift June 8, 2021, 1:00 PM

Problem & Nursing


Diagnosis

“I’m anxious right now. I seem to feel that the world is ending. I need
the cure, that $4-dollar worth of cure just to make me feel relaxed.” As
S
verbalized.

(+) Anxiety, (+) Profuse Sweating, Pulse rate of 136 bpm, (+)
Vomiting, (+) Hand tremors,

A Anxiety r/t cessation of alcohol use

At the end of 3 hours nursing intervention, the patient will be able to


feel relaxed. Specifically: Display a normal vital sign especially PR in
between the range of 60-100bmp. Verbalize absence of or decrease
P in subjective distress. Have posture, facial expressions, gestures, and
activity levels that reflect decreased distress such as calm and stable.
Established a trusting relationship by frequent contact and being non-
judgmental; Project an accepting attitude; Used empathy to encourage
patient to interpret the anxiety symptoms as normal; if irrational
I thoughts were present, offered patient an accurate information and
encourage him to talk about the meaning of the events contributing to
anxiety; Encouraged to use positive self-talk; Explained all activities,
procedures, and issues that involve the patient. Used calm, slow
speech and validate patient’s understanding. Encouraged deep
breathing exercises; Maintained quiet and calm surroundings. Used
guided imagery to decrease anxiety; Provided with a means to listen
to music of their own choice. Used therapeutic touch and healing
touch techniques. Administered diazepam (Valium) 5mg q8 as
ordered.
After 3 hours of nursing intervention, the patient was able to display
normal PR of 80 bpm; He verbalized that he feels better; Have a calm
and stable posture which reflects decreased distress. (-) Anxiety, (-)
E Profuse Sweating, (-) Hand tremors, (+) nauseated

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy