SOAPIE CHARTING

(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

Age: 4 yrs old Sex: F CC: Hypoxemia (SPO2 level <95%)

Medical Diagnosis: Impaired gas exchange r/t to altered alveolar-capillary membrane changes AEB SPO2 level of
92% with O2 s/t PCAP-C

DATE, PROGRESS NOTES

TIME, AND
SHIFT

April 18, S-None-------------------------------------------------------------------------------------------------------------

2020
O-PR 125 bpm; SPO2 92% with 02; WBC of 14,000; irregular, shallow breaths through mouth; uses
10 AM accessory muscles for breathing; unable to breath in supine position; presence of bilateral coarse crackles
on lower lobes with decreased breath sounds at posterior
3AM-11AM
area-----------------------------------------------------------------------------------------------------

A-Impaired gas exchange r/t to altered alveolar-capillary membrane changes AEB SPO2 level of 92%
with O2 s/t PCAP-C---------------------------------------------------------------------------

P- Will demonstrate ease of respiration without the use of accessory muscles and have decreased pulse
rate, within 8 hours of nursing duty; exhibit and maintain clear lung fields and remain free of signs of
respiratory distress; will demonstrate improved ventilation and adequate oxygenation as evidenced by
blood gas levels within normal parameters for that client within 3 days of nursing
duty--------------------------------------------------------------------------

I-Monitored respiratory rate, depth, and ease of respiration; auscultated breath sounds every 1 to 2 hours,
to assess airway obstruction; positioned the pt. in a semirecumbent position with the head of the bed at a
30- to 45- degree angle; facilitated pt’s deep breathing and controlled coughing; scheduled nursing care;
monitored arterial blood gases 30 to 60 minutes after oxygen was started; assessed nutritional status
including serum albumin level and body mass index; monitored oxygen saturation continuously using
pulse oximetry; monitored signs of psychological distress including anxiety, agitation, and
insomnia------------------------------------------------------------------------------------------------------------

E- Decreased pulse rate and reported ease of respiration with the aid of oxygen therapy, and no longer
used accessory muscles during respiration, within 8 hours of nursing duty; did not exhibit nor maintain
clear lung fields with persistent signs of respiratory distress present; minor improvement in ventilation
compared prior to admission was noted------------

Patient’s Name / Room No. | 1

 FDAR CHARTING
(Focus-Data-Action-Response)

Age: 4 yrs old Sex: F CC: Hypoxemia

Medical Diagnosis: Impaired gas exchange r/t to altered alveolar-capillary membrane changes AEB SPO2 level of
92% with O2 s/t PCAP-C

Date, FOCUS PROGRESS NOTES

Time,
and
Shift

Patient’s Name / Room No. | 2

 April 18, Impaired gas exchange r/t to D-PR 125 bpm; irregular, shallow breaths through mouth; uses accessory
2020 altered alveolar-capillary muscles for breathing; unable to breathe in supine position; presence of
membrane changes AEB bilateral coarse crackles on lower lobes with decreased breath sounds at
10 AM SPO2 level of 92% with O2 s/t posterior area.
PCAP-C
3AM-
11AM A-Monitored respiratory rate, depth, and ease of respiration; auscultated
breath sounds every 1 to 2 hours, to assess airway obstruction; positioned
the pt. in a semirecumbent position with the head of the bed at a 30- to 45-
degree angle; facilitated pt’s deep breathing and controlled coughing;
scheduled nursing care; monitored arterial blood gases 30 to 60 minutes
after oxygen was started; assessed nutritional status including serum
albumin level and body mass index; monitored oxygen saturation
continuously using pulse oximetry; monitored signs of psychological distress
including anxiety, agitation, and
insomnia-------------------------------------------------------------------

R-Decreased pulse rate and reported ease of respiration with the aid of
oxygen therapy, and no longer used accessory muscles during respiration,
within 8 hours of nursing duty; did not exhibit nor maintain clear lung fields
with persistent signs of respiratory distress present; minor improvement in
ventilation compared prior to admission was
noted------------------------------------------------------------------------

SOAPIE CHARTING
(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

Age: 4 yrs old Sex: F CC: Dyspnea

Medical Diagnosis: Ineffective airway clearance r/t second-hand smoke exposure

DATE, PROGRESS NOTES

TIME, AND
SHIFT

Patient’s Name / Room No. | 3

 April 18, S- Father smokes 2 packs a day for 8 years-------------------------------------------------------------
2020
O- RR 44cpm; costal breathing through mouth; unable to breathe in supine position; presence of coarse
10 AM crackles on lower lobes with decreased breath sounds at posterior
area------------------------------------------------------------------------------------------------------------------
3AM-11AM

A-Ineffective airway clearance r/t second-hand smoke exposure----------------------------------

P- Demonstrates effective coughing and clear breath sounds; maintains a patent airway, after 8 hours of
nursing duty; can identify and avoid specific factors that inhibit effective airway clearance; classify
methods to enhance secretion removal, after 16 hours of nursing
duty--------------------------------------------------------------------------------------------------------

I- Auscultated breath sounds every 1 to 4 hours; monitored respiratory patterns, including rate, depth, and
effort; monitored blood gas values and pulse oxygen saturation levels as available; positioned the pt. to
optimize respiration (e.g head of bed elevated 30 to 45 degrees); taught deep breathing and controlled
coughing; encouraged activity and ambulation as tolerated; encouraged fluid intake of up to 2500 mL/day
within cardiac or renal reserve; educated parents about the effects of secondhand smoking; administered
oxygen as ordered by the physician-------------------------------------------------------------------------

E- After eight (8) hours of nursing duty, demonstrated effective coughing but failed to clear breath sounds
with audible rales still present during auscultation and in turn did not maintain patent airway; after 16
hours, pt. and SO identified cigarette smoke as specific factor that inhibits effective airway clearance and
thus SOs endeavored to reduce pt.’s exposure by avoiding smoking at home and classified increased fluid
intake and controlled breathing as viable method to enhance secretion
removal-------------------------------------------

FDAR CHARTING
(Focus-Data-Action-Response)

Age: 4 yrs old Sex: F CC: Dyspnea

Medical Diagnosis: Ineffective airway clearance r/t second-hand smoke exposure

Date, FOCUS PROGRESS NOTES

Time,
and

Patient’s Name / Room No. | 4

 Shift

April 18, Ineffective airway D-RR 44cpm; costal breathing through mouth; unable to breathe in supine position;
2020 clearance r/t presence of coarse crackles on lower lobes with decreased breath sounds at
second-hand smoke posterior area-------------------------------------------------------------------------
10 AM exposure

3AM- A-Auscultated breath sounds every 1 to 4 hours; monitored respiratory patterns,

11AM including rate, depth, and effort; monitored blood gas values and pulse oxygen
saturation levels as available; positioned the pt. to optimize respiration (e.g head of
bed elevated 30 to 45 degrees); taught deep breathing and controlled coughing;
encouraged activity and ambulation as tolerated; encouraged fluid intake of up to
2500 mL/day within cardiac or renal reserve; educated parents about the effects of
secondhand smoking; administered oxygen as ordered by the physician--------------

R-After eight (8) hours of nursing duty, demonstrated effective coughing but failed to
clear breath sounds with audible rales still present during auscultation and in turn did
not maintain patent airway; after 16 hours, pt. and SO identified cigarette smoke as
specific factor that inhibits effective airway clearance and thus SOs endeavored to
reduce pt.’s exposure by avoiding smoking at home and classified increased fluid
intake and controlled breathing as viable method to enhance secretion
removal--------------------

SOAPIE CHARTING
(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

Age: 4 yrs old Sex: F CC: Partial airway obstruction

Medical Diagnosis: Ineffective Breathing Pattern r/t inflamed bronchial passages, coughing

DATE, PROGRESS NOTES

Patient’s Name / Room No. | 5

 TIME, AND
SHIFT

April 18, S- None------------------------------------------------------------------------------------------------------------

2020
O- Irregular, shallow breaths through mouth; use of accessory muscle for breathing; unable to breathe in
10 AM supine position; audible breath sounds within a feet, cough, bilateral coarse
crackles---------------------------------------------------------------------------------------------------
3AM-11AM

A-Ineffective Breathing Pattern r/t inflamed bronchial passages, coughing----------------------

P- Will demonstrate ability to perform pursed-lip breathing and controlled breathing; report ability to
breathe comfortably; can identify and avoid specific factors that exacerbate episodes of ineffective
breathing patterns, practice physiotherapy, show proper positioning when SOB occurs. Demonstrate
oxygen saturation within 94%-100%, temperature range of 36.5*C to 37.2*C, heart rate within 80-20 bpm.
and manifest absence of cough, nasal discharge ,nausea and
vomiting-----------------------------------------------------

I- Monitored respiratory rate, depth, and ease of respiration; noted pattern of respiration; documented use
of accessory muscles, nasal flaring, retractions, irritability, confusion, or lethargy; auscultated breath
sounds, noting decreased or absent sounds, crackles, or wheezes; observed the color of tongue, oral
mucosa, and skin for signs of cyanosis; taught how to execute the pursed-lip breathing; practiced
physiotherapy; encouraged her to cough during and after treatment; assessed and recorded any side
effects; administered PEN-G as prescribed by the physician-------------------------------------------------------------

E- Demonstrated ability to perform pursed-lip breathing and controlled breathing, after 8 hours of nursing
duty; reported ability to breathe comfortably as manifested by not using accessory muscles and is able to
breathe in a supine position; identified and avoided specific factors that can trigger episodes of ineffective
breathing patterns, after 16 hours of nursing
duty--------------------------------------------------------------------------------------------------------

FDAR CHARTING
(Focus-Data-Action-Response)

Age: 4 yrs old Sex: F CC: Partial airway obstruction

Medical Diagnosis: Ineffective Breathing Pattern r/t inflamed bronchial passages, coughing

Patient’s Name / Room No. | 6

 Date, FOCUS PROGRESS NOTES
Time,
and
Shift

April 18, Ineffective Breathing D- Irregular, shallow breaths through mouth; use of accessory muscle for
2020 Pattern r/t inflamed breathing; unable to breathe in supine position; audible breath sounds within a
bronchial passages, feet---------------------
10 AM coughing

3AM- A- Monitored respiratory rate, depth, and ease of respiration; noted pattern of
11AM respiration; documented use of accessory muscles, nasal flaring, retractions,
irritability, confusion, or lethargy; auscultated breath sounds, noting decreased or
absent sounds, crackles, or wheezes; observed the color of tongue, oral mucosa,
and skin for signs of cyanosis--------------------------------------------------------

R-Demonstrated ability to perform pursed-lip breathing and controlled breathing,

after 8 hours of nursing duty; reported ability to breathe comfortably as manifested
by not using accessory muscles and is able to breathe in a supine position;
identified and avoided specific factors that can trigger episodes of ineffective
breathing patterns, after 16 hours of nursing
duty---------------------------------------------------

SOAPIE CHARTING
(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

Patient’s Name / Room No. | 7

Age: 4 yrs old Sex: F CC: On & Off Fever
Medical Diagnosis: Ineffective thermoregulation r/t disease process of bacterial pneumonia as evidenced by
temperature of 38.2 degrees celsius, and irregular and shallow breathing

DATE, PROGRESS NOTES

TIME, AND
SHIFT

April 18, S- None------------------------------------------------------------------------------------------------------------

2020
O- T 37.9°C (latest), febrile; RR: 44 cpm, tachypnea; PR: 125 bpm, tachycardia; SPO2: 92% with 02,
10 AM hypoxemia; on & off fever 2 days prior to admission; temperature went up to 38.8°C, 3hrs prior to
admission; temperature of 38.2°C upon admission-------------------------
3AM-11AM

A-Ineffective thermoregulation r/t disease process of bacterial pneumonia as evidenced by temperature of

38.2 degrees celsius, and irregular and shallow breathing-------------------

P- Will attain a stabilized temperature within normal range after 8 hours of duty; be able to sustain
adequate/normal self-thermoregulation; can explain measures needed to maintain normal temperature
after 3 days of nursing duty------------------------------------------------------

I- Assessed the patient’s vital signs at least every four hours; removed excessive clothing, blankets and
linens, and adjusted the room temperature; offered a tepid sponge bath; elevated head of the bed;
documented presence or absence of sweating as the body attempts to increase heat loss by evaporation;
encouraged increased fluid intake by mouth; promoted bed rest; modified cooling measures based on the
patient’s physical response; administered Paracetamol and Pen-G 200,000U as ordered by the
physician----

E- Attained a stabilized temperature within normal range, after 8 hours of nursing duty; was able to
sustain adequate self-thermoregulation and could explain measures needed to maintain normal
temperature, after 3 days of nursing duty--------------------------------------------

FDAR CHARTING
Patient’s Name / Room No. | 8
 (Focus-Data-Action-Response)

Age: 4 yrs old Sex: F CC: On & Off Fever

Medical Diagnosis: Ineffective thermoregulation r/t disease process of bacterial pneumonia as evidenced by
temperature of 38.2 degrees celsius, and irregular and shallow breathing

Date, FOCUS PROGRESS NOTES

Time,
and
Shift

April Ineffective thermoregulation r/t D-T 37.9°C (latest), febrile; RR: 44 cpm, tachypnea; PR: 125 bpm,
18, disease process of bacterial tachycardia; SPO2: 92% with 02, hypoxemia; on & off fever 2 days
2020 pneumonia as evidenced by prior to admission; temperature went up to 38.8°C, 3hrs prior to
temperature of 38.2 degrees celsius, admission; temperature of 38.2°C upon
10 AM and irregular and shallow breathing admission----------------------------------------------------------
3AM-
11AM A-Assessed the patient’s vital signs at least every four hours;
removed excessive clothing, blankets and linens, and adjusted the
room temperature; offered a tepid sponge bath; elevated head of
the bed; documented presence or absence of sweating as the body
attempts to increase heat loss by evaporation; encouraged
increased fluid intake by mouth; promoted bed rest; modified
cooling measures based on the patient’s physical response;
administered Paracetamol and Pen-G 200,000U as ordered by the
physician-------------------------------------------------------------------

R- Attained a stabilized temperature within normal range, after 8

hours of nursing duty; was able to sustain adequate self-
thermoregulation and could explain measures needed to maintain
normal temperature, after 3 days of nursing
duty--------------------------------------------------------------------------

Patient’s Name / Room No. | 9

 SOAPIE CHARTING
(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

Age: 4 yrs old Sex: F CC: Nausea and vomiting

Medical Diagnosis: Risk for deficient fluid volume r/t excessive losses through normal routes

DATE, PROGRESS NOTES

TIME, AND
SHIFT

April 18, S- None------------------------------------------------------------------------------------------------------------

2020
O- Fever, nausea, vomiting, tachypnea-------------------------------------------------------------------
10 AM
A- Risk for deficient fluid volume r/t excessive losses through normal routes-------------------
3AM-11AM
P- Will manifest negative signs of nausea and vomiting; have adequate fluid volume; family will be able to
verbalize awareness of causative factors and behaviors essential to correct fluid deficit; family will be able
to verbalize knowledge of care, after 8 hours of nursing duty; urine output will be greater than or equal to
30ml/hr; will manifests normal skin turgor and absence of
orthostasis---------------------------------------------------------------------

I- Provided oral care after the client vomits; assessed and recorded IV fluids and condition of IV site every
hour, vital signs every 4 hrs, and signs/symptoms of deficient fluid volume every 4 hours and PRN;
assessed and documented (1) the onset, intensity, character, location, duration, aggravating factors, and
relieving factors; (2) skin turgor and oral mucous membranes for signs of dehydration; (3) color and
amount of urine; (4) abdomen and listened to bowel sounds frequently, decreased, absent, or hyperactive
data are noted; reported urine output less than 30 ml/hr for 2 consecutive hours; urged pt. to drink the
prescribed amount of fluid; monitored pt’s mental status every two hours; taught family about care;
assessed and recorded family’s knowledge of and participation in care regarding child’s need for
appropriate fluids, monitoring intake and output, etc.; provided awareness on causative factors and
behaviors related to nausea and vomiting; administered Zinc sulfate 2mL PO as ordered by the
physician-------------------------------------

E- Manifested negative signs of nausea and vomiting, have adequate fluid volume as evidenced by
adequate fluid intake, adequate urine output, urine specific gravity from 1.008 to 1.020, moist mucous
membranes, and rapid skin recoil; and family verbalized awareness of causative factors and behaviors
essential to correct fluid deficit, after 8 hours of nursing duty; was normovolemic as evidenced by urine
output greater than 30ml/hr, normal skin turgor, and absence of orthostasis, after 3 days of nursing
duty---------

Patient’s Name / Room No. | 10

 FDAR CHARTING
(Focus-Data-Action-Response)

Age: 4 yrs old Sex: F CC: Nausea and vomiting

Medical Diagnosis: Risk for deficient fluid volume r/t excessive losses through normal routes

Date, FOCUS PROGRESS NOTES

Time,
and
Shift

April 18, Risk for deficient fluid D-Fever, nausea, vomiting, tachypnea----------------------------
2020 volume r/t excessive
losses through normal A-Provided oral care after the client vomits; assessed and recorded IV fluids and
10 AM routes condition of IV site every hour, vital signs every 4 hrs, and signs/symptoms of
3AM- deficient fluid volume every 4 hours and PRN; assessed and documented (1) the
11AM onset, intensity, character, location, duration, aggravating factors, and relieving
factors; (2) skin turgor and oral mucous membranes for signs of dehydration; (3)
color and amount of urine; (4) abdomen and listened to bowel sounds frequently,
decreased, absent, or hyperactive data are noted; reported urine output less than
30 ml/hr for 2 consecutive hours; urged pt. to drink the prescribed amount of fluid;
monitored pt’s mental status every two hours; taught family about care; assessed
and recorded family’s knowledge of and participation in care regarding child’s need
for appropriate fluids, monitoring intake and output, etc.; provided awareness on
causative factors and behaviors related to nausea and vomiting; administered Zinc
sulfate 2mL PO as ordered by the physician---------------

R-Manifested negative signs of nausea and vomiting, have adequate fluid volume
as evidenced by adequate fluid intake, adequate urine output, urine specific gravity
from 1.008 to 1.020, moist mucous membranes, and rapid skin recoil; and family
verbalized awareness of causative factors and behaviors essential to correct fluid
deficit, after 8 hours of nursing duty; was normovolemic as evidenced by urine
output greater than 30ml/hr, normal skin turgor, and absence of orthostasis, after 3
days of nursing duty-----------

Patient’s Name / Room No. | 11

 SOAPIE CHARTING
(Subjective-Objective-Analysis-Plan-Intervention-Evaluation)

Age: 4 yrs old Sex: F CC: Tachypnea

Medical Diagnosis: Activity Intolerance

DATE, PROGRESS NOTES

TIME, AND
SHIFT

Patient’s Name / Room No. | 12

 April 18, S-N/I---------------------------------------------------------------------------------------------
2020
O- RR: 44 cpm,PR: 125 bpm, Dyspnea, Tachypnea and weakness due to ineffective breathing
10 AM ---------------------------------------------------------------------------------------------------------
3AM-11AM
A- Activity intolerance r/t imbalance between oxygen supply and demand---------------------

P- Will demonstrate an increase in activity as manifested by gradual tolerance to active ROM and and
achieve desired activity level, progressively, with no intolerance symptoms noted, such as respiratory
compromise--------------------------------------------------------------------

I- Evaluated response to activity. Noted reports of dyspnea, increased weakness and fatigue, and
changes in vital signs during and after activities.Provided a quiet environment and limit visitors during the
acute phase, as indicated. Have encouraged use of stress management and diversional activities as
appropriate. Explained the importance of rest in the treatment plan and necessity for balancing activities
with rest. Assisted the client to assume a comfortable position for rest and sleep Assist with self-care,
ambulation and daily living activities as necessary. Provided for patient’s progressive increase in activities
during the recovery phase. Lastly, organized nursing care to allow child uninterrupted rest-

E- Demonstrated an increase in activity as manifested by gradual tolerance to active ROM.Promoted

optimal recovery through comfortable sleeping position and organization of uninterrupted rest; after 3
clinical hours. Decreased heart workload through assisted self-care, ambulation and daily living activities
whilst providing for progressive increase in activities, after 3 days of
duty---------------------------------------------------------------------------------

FDAR CHARTING
(Focus-Data-Action-Response)

Age: 4 yrs old Sex: F CC: Tachypnea

Medical Diagnosis: Activity Intolerance

Date, FOCUS PROGRESS NOTES

Time,
Patient’s Name / Room No. | 13
 and
Shift

April 18, Activity D- RR: 44 cpm,PR: 125 bpm, Dyspnea, Tachypnea and Weakness due to ineffective
2020 Intolerance breathing-----------------------------
10 AM
A- Evaluated response to activity. Noted reports of dyspnea, increased weakness and
3AM- fatigue, and changes in vital signs during and after activities.Provided a quiet environment
11AM and limit visitors during the acute phase, as indicated. Have encouraged use of stress
management and diversional activities as appropriate. Explained the importance of rest in
the treatment plan and necessity for balancing activities with rest. Assisted the client to
assume a comfortable position for rest and sleep Assist with self-care, ambulation and daily
living activities as necessary. Provided for patient’s progressive increase in activities during
the recovery phase. Lastly, organized nursing care to allow child uninterrupted
rest--------------------

R- Demonstrated an increase in activity as manifested by gradual tolerance to active

ROM.Promoted optimal recovery through comfortable sleeping position and organization of
uninterrupted rest; after 3 clinical hours. Decreased heart workload through assisted self-
care, ambulation and daily living activities whilst providing for progressive increase in
activities, after 3 days of duty-----------------------------------------

Patient’s Name / Room No. | 14