SOAPIE
Subjective
Severe vomiting, fever and
right iliac pain
“Aray ! masakit ang aking
tyan. Tulungan niyo po
ako.” Verbalized by the
patient. While in stooped
position and crying loudly.
Intense pain at Mc
Burney’s point.
Objective Assessment
Body Temperature: 38.5°C Risk for infection related to
acute pain resulting from
WBC Count 25,000/mm increased WBC count
>4,500—11,000/mm and
increased body temp.
>36.6 °C.
Planning
The client will display relax
behavior and talk about his
experienced regarding the
pain after the 8 hours of
intervention.
At the end of 8 hours of
shift, patient will describe
satisfactory pain control at
a level less than 3 on a
rating scale of 0 to 10 using
a face scale.
Symptoms of infection will
decrease such as lowering
count of WBC From
25,000/mm to 10,000/mm
and the body temp. of the
client will decrease from
38.5 °C to 36.6 °C.
Implementation
Communicate with the
client using therapeutic
treatment by letting
himself express his
emotions due to acute
pain.
The client will evaluate the
pain using face pain scale (0-
10).
Administer pain medication
as per doctor’s order.
Evaluation
The goal is achieved and
the client rates the face
pain level scale of 2 out of
10 and shows a relax mood
while lying in bed.
Decrease count of WBC
From 25,000/mm to
10,000/mm and the body
temp. of the client
decrease from 38.5 °C to
36.6 °C. shows that the
infection are already
alleviated.

Last Name: First Name:
Gen Robert
Attending Physician:
Dr. Hernandez, R. Romulo
DATE/TIME SO
5/4/19 Subjective Data:
- Severe vomiting, fever
6:30 am and right iliac pain
- Crying loudly
- “Aray ! masakit ang
aking tyan. Tulungan
niyo po ako.”
Verbalized by the
patient.
- Intense pain at Mc
Burney’s point.
Objective Data:
- PR-70 bpm
- RR- 25 bpm
- Body Temperature:
38.5°C
- elevated WBC Count
25,000/mm
NURSING SERVICE DEPARTMENT
NURSE’S NOTE- (SOAPIE)
Date Admitted:
5/4/19
NEEDS & PROBLEM:
Problem or Actual
Risk for infection as
evidence by an increased in
WBC count
>4,500—11,000/mm,
increased body temp.
>36.6 °C. and right iliac
pain at Mc burney’s point
“Aray ! masakit ang
aking tyan. Tulungan
niyo po ako.” Verbalized
by the patient while
crying loudly.
Room No. Bed No. Hosp. No.
406 04 18975
Age: Sex: Civil
10 years old Male Status:
Single
Nursing Intervention Evaluation & to
Endorse
The client will evaluate the pain using face pain scale The goal was met and the
(0-10). Help the client to relax by encouraging to state patient states that the pain
his feelings regarding the pain. level is at rating scale of 2
using a face scale and
Discharge aspirations from vomiting will be further shows a relax mood while
examine by the laboratory and the amount will be lying in bed.
noted. Refer to the physician for consultation.
The client displays relax
Administer pain medication as per doctor’s order. behavior and talk about
what he experienced
Assist patient during activities such as helping regarding the pain after 8
positioning in bed and avoiding the location of affected hours.
area and monitor vital signs every 1 hour.
Decrease count of WBC
From 25,000/mm to
10,000/mm and the body
temp. of the client
decrease from 38.5 °C to
36.6 °C. shows that the
infection are already
alleviated.