ACTUAL SOAPIE

S - “Hindi ako nagbaBT kase wala pang pera”- as verbalized by the patient
O - Received on bed on supine position conscious and coherent, with intact
and unsoaked incision dressing, (-) breast engorgement, urine (1), (-)BM,
unsoaked vagial/perineal pads with moderate amount of lochia serosa, (-)Homan’s
sign, ambulatory, pale buccal mucosa and conjunctiva, hgb count (77), hct (0.33),
with initial vital signs taken as follows: BP- 120/80 mmHg, PR-83 bpm, RR-26
bpm, Temp.-36.4 oC.
A - Altered Tissue Perfusion r/t decrease hgb(77), hct(0.33) counts
P - After 2o of nursing intervention, the patient will verbalize understanding
of the condition, treatment/therapy regimen, and will demonstrate behavioral
changes to improve circulation.
I - Assessed for physical manifestations of anemia
- Assessed for factors that could precipitate to anemia such as bleeding on
incision site, excessive lochia and diet.
- Assessed diet/food preference
- Encouraged to increase intake of food rich in iron such as animal liver &
green & leafy vegetables when in DAT status
- Instructed to watch for sign of bleeding on incision site (soaked dressing)
and increase in lochia
- Instructed compliance to oral iron supplement intake
- administered due medication
E - Patient verbalized understanding of condition and therapeutic regimen and
demonstrated behavioral changes to improve circulation

S - “Eku migalo masakit kasi, maghilab ya ing tiyan ku dati, tatakut naku”- as
verbalized by the patient
O - Received on bed on supine position conscious and coherent, with intact
and unsoaked incision dressing, (-) breast engorgement, urine (1), (-)BM,
unsoaked vagial/perineal pads with moderate amount of lochia serosa, (-)Homan’s
sign, ambulatory, pale buccal mucosa and conjunctiva, hgb count (77), hct (0.33),
with initial vital signs taken as follows: BP- 160/90 mmHg, PR-90 bpm, RR-23
bpm, Temp.-36.4oC.
A - Impaired Physical Mobility r/t pain and discomfort secondary to episodes
of uterine contractions: preterm labor
P - After 2 hours of nursing intervention, the patient will display increase in
activity level and will verbalize understanding to maintain safety.
I - Monitored V/S
- Assessed for episodes of preterm uterine contraction
- Assessed for degree of discomfort that limits patient’s movements
- Assisted in performing ADL
- Instructed to increase food rich in calorie sch as fruits, vegetables, rice,
bread, etc. to regain energy
- Instructed patient to perform ADL as tolerated and gently