The client, a 54-year-old female, complained of hip and leg discomfort after sitting for over 2 hours. Upon assessment, the nurse found the client's temperature, pulse, respiration, and blood pressure to be normal but noticed weak pulses in her lower extremities. The nurse diagnosed the client with impaired comfort related to prolonged sitting. The nurse's plan was to assist with proper bed positioning, massage the client's legs to improve blood flow, perform range of motion exercises, and teach leg massage techniques to relieve pain. After interventions, the client felt more comfortable and relieved.
The client, a 54-year-old female, complained of hip and leg discomfort after sitting for over 2 hours. Upon assessment, the nurse found the client's temperature, pulse, respiration, and blood pressure to be normal but noticed weak pulses in her lower extremities. The nurse diagnosed the client with impaired comfort related to prolonged sitting. The nurse's plan was to assist with proper bed positioning, massage the client's legs to improve blood flow, perform range of motion exercises, and teach leg massage techniques to relieve pain. After interventions, the client felt more comfortable and relieved.
The client, a 54-year-old female, complained of hip and leg discomfort after sitting for over 2 hours. Upon assessment, the nurse found the client's temperature, pulse, respiration, and blood pressure to be normal but noticed weak pulses in her lower extremities. The nurse diagnosed the client with impaired comfort related to prolonged sitting. The nurse's plan was to assist with proper bed positioning, massage the client's legs to improve blood flow, perform range of motion exercises, and teach leg massage techniques to relieve pain. After interventions, the client felt more comfortable and relieved.
The client, a 54-year-old female, complained of hip and leg discomfort after sitting for over 2 hours. Upon assessment, the nurse found the client's temperature, pulse, respiration, and blood pressure to be normal but noticed weak pulses in her lower extremities. The nurse diagnosed the client with impaired comfort related to prolonged sitting. The nurse's plan was to assist with proper bed positioning, massage the client's legs to improve blood flow, perform range of motion exercises, and teach leg massage techniques to relieve pain. After interventions, the client felt more comfortable and relieved.
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UNIVERSITY OF THE PHILIPPINES MANILA
The Health Sciences Center
COLLEGE OF NURSING Sotejo Hall, Pedro Gil Street, Manila N10 Nursing Foundations I SOAPIE DOCUMENTATION Name of Student: Jubilee Christiene M. Ang Date: November 9, 2015 and Time: 10:00 A.M. Name of Client: Victoria Cureg Age: 54 Sex: F Civil Status: Single
SUBJECTIVE OBJECTIVE ANALYSIS PLAN IMPLEMENTATION EVALUATION
Hihiga na ako, T-36.7C Nursing Diagnosis: Assist client The nurse had The client kasi ang sakit na (Axilla) Impaired Comfort towards assisted the preferred lying ng binti ko, PR- 70 bpm related to prolonged proper bed- client towards in the bed nangangawit RR- 21 period of sitting positioning proper bed- sideways and na. breaths per The client feels hip which positioning. felt more Nakaupo ako minute and leg discomfort prevents her The nurse also comfortable kanina pang Blood after a prolonged from feeling explained the upon being 8:00 am. Pressure- period (2 hours) of more hip and proper lying assisted by the Ang talagang 130/80 sitting on a chair leg posture while nurse. naka-aapekto sa BMI Status: beside her bed. discomfort. assisting the akin yung Obese 1 The client client. pagsakit ng Capillary verbalizes that her tuhod ko tsaka Refill, 3 legs get sore easily The nurse balakang kapag seconds because of her massaged the The client matagal akong Weak current body and Massage the legs and feet verbalized Oo, nakaupo o peripheral its amount of body clients legs of the client mas nawala na nakatayo, o fat. and feet to Nurse taught ang sakit after pulses at kaya The client has improve the client and the massage popliteal, naglalakad. weak peripheral blood flow clients son Ganito kasi ako posterior pulses particularly about the and to kaya madali tibial and at the lower region release massage akong dorsalis of her body. Her tension. techniques to mangawit. Dahil pedis artery capillary refill soothe leg sa sa sobrang Client was duration is 3 pain. bigat ko. only sitting seconds. This (referring to her on a chair implies a decrease The client felt body) beside her in amount of blood The nurse had more Hindi ko bed from flow at the leg assisted the comfortable maexplain yung 8:00 A.M. to region. Perform ROM clients leg and relieved sakit, pero 10:00 P.M. exercises while after all the parang yung (approx. 2 with the performing the nursing normal lang na hrs) assistance of ROM leg interventions pakiramdam Client was the nurse in exercises made by the kapag pagod trying to order to nurse. ka. soothe her increase legs by blood flow caressing her legs (hinihimas- himas) Client lied down on her bed