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nurses are still learning the right way on how to make a good SOAPIE. This post will give you some tips on
how to do so.
3. NANDA out!
If its your first time to write a SOAPIE, its okay to use the NANDA, but if your a 4th year and you would be
graduating in the next (lets say) 2 weeks shame on you. (For those who doesnt know what NANDA is, it is the
best friend and most overused book by a nursing student).
So going back, if its your first semester for your hospital exposure, go ahead use your NANDA
and rememberthe cues, the related factors, the interventions and what would you want the patient achieve.
Dont be NANDA dependent, nandammit!
and yes there are a lot of instances where acute pain be used that is why if NANDA would write down
specifically all the related factors it would be as thick as the MS book of Joyce Black.
Some nursing diagnoses can stand alone even without related factors like Hyperthermia. Although these type
of diagnoses are limited to SOAPIEs and not on care plans.
Specific and Measurable. End your planning with AEB and then cues that you would assess to
confirm whether you have achieved your goal. Example: the patient will establish airway patency as
evidenced by (AEB) effective respirations, respiratory rate within normal range and demonstration of deep
breathing exercises and effective coughing exercises.
Attainable and Realistic. A case with severe pneumonia: After 1 hour of NI the patient will establish
normal respiration AEB. This is quite unattainable (go figure).
Time Bound. Make sure that the time youve put in your planning is enough to achieve your desired
outcomes.
Be patient centered as much as possible. The patient is at the center of planning because he/she is the chief
decision maker of what treatment plans he/she would allow. You patient is not the significant other. Be cautious
of also using the phrase verbalize understanding of to pediatric patients. Also, dont restrict your planning or
goals on whats written on NANDA.
7. Interventions
You can start with established rapport, then assess the general condition, monitor the vital signs and thenyou
can start writing the real interventions in your SOAPIE.
Make sure that all assessment-like interventions should be within the first few lines of your
Note that the assessment-like interventions are at the first few lines
interventions. Assessment-like interventions are those interventions wherein you would say that you assessed
for this and that like monitored hydration status, auscultated bowel sounds, assessed neuro vital signs.
The rest of your interventions should be next. Dont ever, ever forget to shift to past tense. Put dependent
nursing interventions last like administered medications.
Also remember some templates for interventions like Above IVF consumed hooked #2 D5LRS
1L, hooked O2 inhalation regulated at 2-3 LPM via nasal canula and especially seen on rounds by Dr. Xyz
with orders made and carried out:
And lastly, always make sure to add in your interventions the explanation of the disease of the client. A good
student nurse knows the importance and impact of health education to the prognosis of the patient.
8. Horray! Evaluation.
Finally, we have arrived at the evaluation. Was your planning or goal met? partially met? or not met? How would
you assess whether they were met? Simple. If you have made a good planning it should have ended with
AEB and then their corresponding cues. These cues are your parameter whether you have met your goal.
As for the example above was your able to manifest effective respiration and rate within normal range? deep
breathing and coughing exercises?
Sample SOAPIE
And lastly, here is an example SOAPIE, with all the things you have learned above can you comment whats
wrong with this SOAPIE?
S > (none) O> Received pt sitting in bed conscious and coherent, with IVF of #7 D5W 1L infusing well
on the right metacarpal vein regulated 30 gtts/min at 300 cc level, without signs of phlebitis or infiltrations.
O2 inhalation therapy via NC regulated @ 2LPM pt appears fatigued and weak, pt is acyanotic, without
pallor, without edema, with pink conjunctiva, moist mucous membranes, capillary refill less than 3 seconds,
poor skin turgor, pt has cough with lung fields clear upon auscultation, with chest pain provoked with
activity, pts heart rate is irregular and bradycardic, with ecchymosis on L forearm, vital signs taken as
follows: BP 90/50 48 22cpm 36.7
P> After 4-5 hours of NI the patient will be able to identify health interventions that will decrease
cardiac workload of the heart
I>
Established rapport
Provided AM care
Seen on rounds by Dr. N with orders given and carried out as follows:
E> Goal met AEB pt was able to identify health interventions that would allow decrease in cardiac work load.