PROBLEM-ORIENTED

CHARTING
MR. HARLEY L. DELA CRUZ, RN, MAN
LECTURER
PROBLEM-ORIENTED
MEDICAL RECORD (POMR)
Introduced in 1969 by LAWRENCE WEED
CASE WESTERN RESERVE UNIVERSITY
Data are recorded and arranged according to the
source of information
The record integrates all data about the problem,
gathered by the members of the health team
The focus of POMR documentation is on the
clients problem, with a structured, logical
format to narrative charting called SOPIE.

FOUR BASIC COMPONENTS OF
POMR
1. Database. Contains all initial information about
the patient.
2. Problem list. Contains all aspects of the persons
life requiring health care.
3. Initial list of orders or care plans.
4. Progress notes:
a. Nurses or narrative notes (SOPIE FORMAT)
b. Flow sheets
c. Discharge notes or referral summaries

SOPIE CHARTING
S: Subjective Data- what the client or family states
O: Objective Data- what is inspected or observed
A: Assessment- conclusion reached on the basis of
data formulated as client problems or nursing
diagnoses
P: Planning- actions to be taken to relieve clients
problem
I: Intervention- measures to achieve an expected
outcome
E: evaluation- effectiveness of intervention


SUBJECTIVE DATA

SUBJECTIVE DATA:(SYMPTOMS) ARE INFORMATION
FROM THE CLIENTS (SOMETIMES FAMILYS) POINT
OF VIEW AND INCLUDE FEELINGS, PERCEPTIONS,
AND CONCERNS.
THE PRIMARY METHOD OF COLLECTING SUBJECTIVE DATA
IS THE INTERVIEW and OBSEVATION. SECONDARY
SOURCES ARE FROM FAMILY, SIGNIFICANT OTHERS,
PATIENTS RECORD/CHART, OTHER HEALTH TEAM
MEMBERS AND RELATED LITERATURES.
EXAMPLE:It happened about an hour ago when my
headache got worse. Now I am nauseated and dizzy,as
verbalized by the client.
headache, nausea, dizziness, pain, DOB, nervousness, vertigo,
tinnitus etc.
OBJECTIVE DATA

OBJECTIVE DATA:(SIGN) ARE OBSERVABLE
AND MEASURABLE INFORMATION THAT IS
OBTAINED THROUGH BOTH STANDARD
ASSESSMENT TECHNIQUES AND THE
RESULTS OF LABORATORY AND
DIAGNOSTIC TESTING.
EXAMPLE:TEMPERATURE: 99F/axilla,PULSE
RATE:100 beats/min., RESPIRATION: 28
breaths/min., BLOOD PRESSURE: 150/90 mmHg,
cannot move left arm, flushed face, face grimace,
vomiting, rales on both lung fields, gait,pallor,skin
lesions, lung sounds diaphoresis,goose-fleshed skin
etc.


ASSESSMENT

ACTUAL NURSING DIAGNOSIS-
indicates that a problem exists and is
composed of the diagnostic label, related
factors and signs and symptoms
Example: Fluid volume deficit related to nausea and
vomiting as manifested by dry skin and mucous
membranes and decreased oral intake of fluids

POTENTIAL NURSING DIAGNOSIS OR RISK
NURSING DIAGNOSIS- indicates that a problem
does not yet exist but special risk factors are
present.
Example: Risk for infection related to presence of invasive
lines(IV line and indwelling catheter)

POSSIBLE NURSING DIAGNOSIS-
indicates a situation in which a problem
could arise unless preventive action is
taken.
Example: Possible imbalanced nutrition: less than body
requirements related to insufficient oral intake.


APPROVED NANDA(North American Nursing Diagnosis
Association) DIAGNOSTIC CATEGORIES


OXYGEN NEEDS-IMPAIRED GAS EXCHANGE, INEFFECTIVE AIRWAY
CLEARANCE, INEFFECTIVE BREATHING PATTERN, POTENTIAL FOR
ASPIRATION
TEMPERATURE MAINTENANCE-POTENTIAL ALTERED BODY
TEMPERATURE, HYPOTHERMIA, HYPERTHERMIA, INEFFECTIVE
THERMOREGULATION
NUTRITIONAL AND FLUID NEEDS- ALTERED NUTRITION:LESS THAN
BODY REQUIREMENTS, FLUID VOLUME DEFICIT-ACTUAL POTENTIAL, FLUID
VOLUME EXCESS, IMPAIRED SWALLOWING
ELIMINATION NEEDS-CONSTIPATION, DIARRHEA, BOWEL INCONTINENCE,
URINARY RETENTION, TOILETING SELF-CARE DEFICIT, STRESS
INCONTINENCE
REST AND SLEEP NEEDS-FATIGUE, SLEEP PATTERN DISTURBANCE
THE NEED FOR PAIN AVOIDANCE-PAIN, CHRONIC PAIN
SEXUAL NEEDS-SEXUAL DYSFUNCTION, ALTERED SEXUAL PATTERN

STIMULATION NEEDS- ACTIVITY INTOLERANCE, POTENTIAL ACTIVITY
INTOLERANCE, IMPAIRED PHYSICAL MOBILITY, SENSORY/PERCEPTUAL
ALTERATIONS-SPECIFY AS VISUAL, AUDITORY KINESTHETIC, GUSTATORY,
TACTILE, OLFACTORY
SAFETY AND SECURITY NEEDS- POTENTIAL FOR INFECTION, POTENTIAL
FOR INJURY, POTENTIAL FOR POISONING. POTENTIAL FOR IMPAIRED
TISSUE INTEGRITY, IMPAIRED SKIN INTEGRITY, ANXIETY, FEAR,
KNOELEDGE DEFICIT, INEFFECTIVE INDIVIADUAL COPING
LOVE AND BELONGING NEEDS- IMPAIRED SOCIAL INTERACTION,
ALTERED PARENTING, PARENTAL ROLE CONFLICT
SPIRITUAL NEEDS- SPIRITUAL DISTRESS
SELF ESTEEM NEEDS-BODY IMAGE DISTURBANCE, DRESSING/HYGIENE
SELF-CARE DEFICIT, SELF-ESTEEM DISTURBANCE,PERSONAL IDENTITY
DISTURBANCE, POWERLESSNESS, DEFENSIVE COPING
SELF-ACTUALIZATION NEEDS-IMPAIRED ADJUSTMENT, ALTERED
GROWTH DEVELOPMENT, HEALTH SEEKING BEHAVIOR



ORGANIZED BY HUMAN RESPONSE PATTERN
PATTERN 1:EXCHANGING-ALTERED NUTRITION: MORE THAN/LESS
THAN BODY REQUIREMENTS, POTENTIAL FOR INFECTION,
DIARRHEA, FLUID VOLUME DEFICIT, IMPAIRED GAS EXCHANGE,
POTENTIAL FOR INJURY, IMPAIRED SKIN INTEGRITY
PATTERN 2: COMMUNICATING: IMPAIRED VERBAL COMMUNICATION
PATTERN 3: RELATING- IMPAIRED SOCIAL INTERACTION, ALTERED
PARENTING, SEXUAL DYSFUNCTION, PARENTAL ROLE CONFLICT
PATTERN 4: VALUING- SPIRITUAL DISTRESS
APPROVED NANDA(North American Nursing Diagnosis
Association) DIAGNOSTIC CATEGORIES


PATTERN 5: CHOOSING- INEFFECTIVE INDIVIDUAL COPING, IMPAIRED
ADJUSTMENT, INEFFECTIVE DENIAL, NONCOMPLIANCE
PATTERN 6: MOVING-IMPAIRED PHYSICAL MOBILITY, ACTIVITY
INTOLERANCE, FATIGUE, SLEEP PATTERN DISTURBANCE,
IMPAIRED SWALLOWING, HYGIENE/DRESSING SELF-CARE DEFICIT,
TOILETING SELF-CARE DEFICIT, ALTERED GROWTH AND
DEVELOPMENT
PATTERN 7: PERCEIVING- BODY IMAGE DISTURBANCE, SELF ESTEEM
DISTURBANCE, PESONALITY IDENTITY DISTURBANCE,
SENSORY/PERCEPTUAL ALTERATIONS, HOPELESS NESS,
POWERLESSNESS
PATTERN 8: KNOWING- KNOWLEDGE D DEFICIT-SPECIFY, ALTERED
THOUGHT PROCESSESS
PATTERN 9: FEELING-PAIN, CHRONIC PAIN, DYSFUNCTIONAL
GRIEVING, POTENTIAL FOR VIOLENCE, POST TRAUMA RESPONSE,
RAPE-TRAUMA SYNDROME, ANXIETY, FEAR



PLANNING

OUTCOME IDENTIFICATION
AND PLANNING
Planning involves developing a proposed course of
action in regard to the clients health status.
The words goals and outcomes are both used to
describe expectations of what is to be achieved as a
result of nursing actions. Goals and outcomes are
measures for determining client progress.

PLANNING

TYPES OF SPECIFIC OBJECTIVES:
SHORT TERM OBJECTIVES-identify outcome in patient's
status or behavior that can be achieve in a matter of hours or
days.
Example: The patients respiration will decrease from 40
breaths/min to below 30 breaths/min within 1 hour.
Return of bowel sounds within 12 hours postop
The patients temp. will decrease from 38.5C to
37.5C after 1 hour of nursing intervention.
After 2 hours of nursing intervention, patient will
verbalize pain rate from 6(moderate) to 3(minimal)or below
based on 1-10 pain rating scale(1-3=minimal; 4-7=moderate
and 8-10=severe).


LONG TERM OBJECTIVES-a statement that outlines the
desired resolution of the nursing diagnosis over a longer
period of time, usually weeks or months.
Example: Self-care of colostomy 1 month after surgery
Patient to state no longer afraid of having severe
pain during during terminal illness from cancer 1 week on IV
morphine.
Reestablishment of patients usual bowel elimination
patterns in 2 months.
Breastfeeding 10-15 min/breast, every 2-5 hours,
within e weeks after delivery.

IMPLEMENTATION

IMPLEMENTATION
NURSING INTERVENTION/ IMPLEMENTATION-
INVOLVES THE EXECUTION OF THE NURSING
CARE PLAN DERIVED DURING PLANNNG OF
CARE.
3 CATEGORIES OF NURSING INTERVENTIONS
Independent nursing interventions- are nursing actions that
are initiated by the nurse and do not require direction or a
order from another health care professional.
Example: positioning of client, assessment, provide
appropriate ventilation, providing appropriate milieu to
promote rest and sleep

Dependent nursing interventions-are nursing actions that
require an order from a physician or another health care
professional.
Example: administration of specific medication prescribed by
the physician.

Interdependent nursing interventions: are nursing actions that
are implemented in a collaborative manner by the nurse in
conjunction with other health care professionals
Example: assisting client to perform an exercise taught by the
physical therapist

EVALUATION

EVALUATION
EVALUATION-involves determining whether the
client objectives of care have been met, partially
meet or not met.Evaluation involves the
evaluation of goal achievement and review of the
nursing care plan
EVALUATION= EVALUATION OF GOAL
ACHIEVEMENT + REVIEW OF THE CARE
PLAN

SOPIE FORMAT CHARTING
SAMPLE: PATIENT WITH KETOACIDOSIS
DATE/
TIME
S: Client states I feel sick all over. Client claims
difficulty in breathing, abdominal pain, and nausea
O: Lung clear, RR 28/min, labored. Abdominal
distended, bowel sounds underactive all four
quadrants, 5+ abdominal pain
A: Alteration in nutrition and comfort R/T
ketoacidosis. Blood sugar 460mg/dl. Ketones
strongly positive, pH <7.3




DATE/
TIME



DATE/
TIME
P: Maintain IV infusion of 0.9%NS with regular
insulin as ordered. NPO. Oral hygiene hourly.
Maintain accurate I&O. Assess for rales,
hypotension, cardiac dysrhythmias. Monitor
blood glucose and electrolytes. SIGNATURE
I: Called Dr. Reyes, blood sugar 460mg/dl, IV
bolus regular insulin given as ordered, 1000ml
0.9%NS infusing @ 1L/H central line 1. 50U
regular insulin in 500 mL NS infusing @ 50
mL/H central line 2. EKG taken. SIGNATURE
E: Lungs clear, RR 24/min, nonlabored, 3+
abdominal pain. Urinary output 750 ml/hour.
Blood glucose 360 mg/dl. SINATURE
End
THANK YOU!!!