SOAPIE AND NCP
Abijah Sebastian J. Bay
BSN 2-3
SITUATION.
Patient Amy, 29 y/o was admitted to the hospital 1 day PTC due to labor pains. She
gave birth to a baby thru NSD and was transferred to the OB ward without
complications. Her baby was roomed-in immediately after 12 hours from birth. Her
OB score is P1G1T1P0A0L1M0. During your round, patient Amy was in pain due to her
episiotomy. Upon assessment, she verbalized a scale of 7/10 in the pain scale. She
barely walks and sit properly. She also looks stressed because she does not know
how to pacify her crying baby and does not know how to start latching on her baby.
She also mentioned that she has no breast milk yet to give her baby. When asked
about her bowel movement, she mentioned that it’s been 2 days that she hasn’t
move her bowel yet. Based on the doctor’s orders; her diet is DAT, on Mefenamic
acid 500mg PRN, Malunggay cap TID, Celgro TID and Iveret forte 500mg TID.
SOAPIE
CUES.
SUBJECTIVE DATA
● Nurse, ang sakit sakit na po ng aking
tahi. Sobrang hapdi!”, as verbalized
by the pt.
● Pt. verbalized a scale of 7/10 in the
pain scale.
CUES.
OBJECTIVE DATA
● Pt. is moaning and crying due to the
pain felt in the area where
episiotomy is done.
● Pt. barely walks and sit properly.
ASSESSMENT.
● Acute pain r/t to post-op surgical
incision
PLANNING.
● Within the 2 hours of nursing
intervention, the pt.’s pain scale will
decrease to at least 3/10 or less.
● The pt.’s non-verbal indicators (such as
moaning, crying from pain) will be
decreased or absent
NURSING INTERVENTION.
● Non-verbal indicators (such as facial grimacing, moaning and crying) was
observed.
● Pt.’s pain using a scale of 0-10 pain scale was assessed.
● Established a supportive accepting relationship by acknowledging the
pain and listening attentively to the pt.’s discussion of pain.
● Nonpharmacological pain management (such as cold Sitz bath, music
therapy etc.) was provided.
● Instructed the pt. with the usage of deep-breathing techniques to
alleviate the pain.
NURSING INTERVENTION.
● Encouraged the pt. to do deep breathing techniques to alleviate the pain.
● Instructed the pt. positions such as side-lying to prevent increase of pain
being felt.
● Vital signs were assessed before administering the prescribed
medication.
● A 500 mg of mefenamic acid PRN was administered to alleviate the pain.
● Health education regarding the time of taking the medication when pain
recurrence occur was provided.
EVALUATION.
GOAL MET
● After the nursing intervention, the pt.
verbalized a scale of 3/10 with the pain
scale.
● Non-verbal indicators (such as
moaning, crying from pain) were
decreased.
NURSING CARE PLAN
ASSESSMENT.
SUBJECTIVE DATA
● Nurse, ang sakit sakit na po ng aking
tahi. Sobrang hapdi!”, as verbalized
by the pt.
● Pt. verbalized a scale of 7/10 in the
pain scale.
ASSESSMENT.
OBJECTIVE DATA
● Pt. is moaning and crying due to the
pain felt in the area where
episiotomy is done.
● Pt. barely walks and sit properly.
DIAGNOSIS.
● Acute pain r/t to post-op surgical
incision
PLANNING.
● Within the 2 hours of nursing
intervention, the pt.’s pain scale will
decrease to at least 3/10 or less.
● The pt.’s non-verbal indicators (such as
moaning, crying from pain) will be
decreased or absent
NURSING INTERVENTION.
● Will observe non-verbal indicators (such as facial grimacing, moaning
and crying).
● Will assess pt.’s pain using a scale of 0-10 pain scale.
● Will establish a supportive accepting relationship by acknowledging the
pain and listening attentively to the pt.’s discussion of pain.
● Will provide nonpharmacological pain management (such as cold Sitz
bath, music therapy etc.).
● Will instruct the pt. with the usage of deep-breathing techniques to
alleviate the pain.
NURSING INTERVENTION.
● Will encourage the pt. to do the deep-breathing techniques when pain
recurrence occurs.
● Will instruct the pt. positions such as side-lying to prevent increase of
pain being felt.
● Will assess vital signs before administering the prescribed medication.
● Will administer a 500 mg of mefenamic acid PRN to alleviate the pain.
● Will provide health education regarding the time of taking the
medication when pain recurrence occurs.
EVALUATION.
AFTER THE NURSING INTERVENTION
● The pt. will be asked about her pain
perception with the usage of the 0-10
pain scale.
● The pt.’s pain of perception will be
assessed by observing for presence of
non-verbal indicators (crying, moaning
etc.)
THANK YOU
FOR LISTENING!
