NURSING MANAGEMENT (Actual SOAPIERs)

Problem: Deficient fluid volume (isotonic, intravascular) related to loose watery stool
(diarrhea) as evidenced by oliguria (concentrated urine), dry skin, dry lips and oral
mucous membranes
Subjective: None
Objective:
The client manifested:
-easy fatigability on November 14, 2016
-oliguria (concentrated urine) on November 21, 2016.
-diarrhea on Novermber 16 and 19, 2016.
-dry skin on November 14-24, 2016.
-dry lips and oral mucous membranes on November 14-24, 2016.
-Loss of weight (-15kg) on November 14-20, 2016.
-Loss of weight (-3kg) on November 20-24, 2016.
-Easy fatigability on November 14, 2016
-Hypotension (100/50) on November 15, 2016.

VS taken as follows:
PR=87 bpm
RR=18 bpm
T=36 C
BP=100/50 mmHg

Assessment:
Deficient fluid volume (isotonic, intravascular) related to loose watery stool (diarrhea) as
evidenced by oliguria (concentrated urine), dry skin, dry lips and oral mucous membranes
Planning:
After 4 hours of nursing interventions, the client will maintain fluid volume as evidenced by
increase of urine output, increase of blood pressure from 100/50 to 110/70 and moist mucous
membranes.
Interventions:
Monitored vital signs and CVP.
Noted presence/degree of postural BP changes.
Observed for temperature elevations/fever.
Palpated peripheral pulses; noted capillary refill, skin color/temperature.
Assessed mentation.
Monitored urinary output. Measured fluid losses from all sources, e.g., gastric losses,
wound drainage, diaphoresis
Weighed daily and compared with 24-hr fluid balance. Mark/measure edematous areas,
such as abdomen, limbs.
Evaluated clients ability to swallow despite having rashes, mouth sores and dryness of
the mouth.
Investigated reports of sudden/sharp chest pain, dyspnea, cyanosis, increased anxiety,
restlessness.
Monitored for sudden/marked elevation of BP, restlessness, moist cough, dyspnea,
basalar crackles, frothy sputum.
Ascertained clients beverage preferences, and set up a 24-hr schedule for fluid intake.
Encourage foods with high fluid content.
Turned frequently, massaged skin, and protected bony prominences.
Provided skin and mouth care

 Provided safety precautions as indicated such as use of side rails, bed in low position and
frequent observation
Monitored laboratory studies as indicated, such as electrolytes, glucose, pH/P CO2,
coagulation studies.
Administered IV solutions as indicated:Isotonic solutions, such as 0.9% NaCl (normal
saline), 5% dextrose/water
Whole blood/packed RBC transfusion, or autologous collection of blood.
Administered sodium bicarbonate, if indicated.

Evaluation:
GOAL MET. The client shall have maintained fluid volume as evidenced by absence of thirst,
increase of blood pressure from 100/50 to 110/70 and moist mucous membranes.

Problem: Fatigue related to anemia, immunosuppression and increased energy demand in

a hyperrmetabolic state secondary to Adenocarcinoma as evidenced by verbalization of
easy fatigability.
Subjective: Parang ang bilis ko mapagod as voiced out by the client.
Objective:
The client manifested:
-easy fatigability noted on November 14, 2016.
-inability to maintain usual routines

VS taken as follows:
PR=87 bpm
RR=18 bpm
T=37.2 C
BP=100/60 mmHg

Assessment:
Fatigue related to anemia, immunosuppression and increased energy demand in a
hyperrmetabolic state secondary to Adenocarcinoma as evidenced by verbalization of easy
fatigability.
Planning:
After 6 hours of nursing interventions, the client will perform activities of daily living and
participate in desired activities at level of ability.

Interventions:
Monitored physiological response to activity, such as changes in BP or heart and
respiratory rate.
Performed pain assessment and provided pain management.
Planned care to allow for rest and uninterrupted sleep periods.
Scheduled activities for periods when client has most energy.
Involved client and SO in schedule planning.
Established realistic activity goals with client.
Assisted with self-care needs when indicated;
Kept bed in low position and pathways clear of furniture; and assisted with ambulation
Encouraged client to do whatever possible, such as self-bathing, sitting up in chair, and
walking.
Increased activity level as individual is able.
Encouraged aerobic exercise, as client is able, with goal of 30 minutes per day.
Encouraged nutritional intake.
Encouraged adequate fluid intake.
Provided supplemental oxygen, as indicated.

Evaluation:
GOAL MET. The client shall have performed activities of daily living and participate in desired
activities at level of ability.

Problem: Acute Pain

Subjective: Pain in RLQ that is characterized by crampy pain, with a scale of 5 out of 10,
localized and intermittent as complained by the client.
Objective:
The client manifested:
-pain in RLQ 5/10 on November 14-20, 2016
-easy fatigability on November 14, 2016
VS taken as follows:
Temp: 36C
PR: 68 beats per minute
RR: 20 breaths per minute
BP: 100/60 mmHg
Assessment:
Acute Pain
Planning:
After 4 hours of nursing interventions, the client will report pain relief as evidenced by a
decrease in pain scale from 5/10 to 2/10.
Interventions:
Monitored and documented characteristics of pain, noting verbal reports, nonverbal cues,
for example, moaning, crying, restlessness, diaphoresis, clutching chest, rapid breathing
and hemodynamic response (BP and heart rate changes).

 Obtained full description of pain from client including location, intensity (0 to 10),
duration, characteristics (dull or crushing), and radiation.
Monitored vital signs.
Provided comfort measures, such as back rubs and position changes.
Assisted with self-care activities.
Encouraged diversional activities, as indicated.
Scheduled care activities to balance with adequate periods of sleep and rest.
Identified and encouraged use of behaviors such as guided imagery, distractions,
visualizations, and deep breathing.
Administered

medications,

as

indicated:

propoxyphene

and

acetaminophen,

acetaminophen and oxycodone, and ketorolac.

Administered supplemental oxygen by means of nasal cannula or face mask, as indicated.
Prepared for/assist with pericardiocentesis or thoracocentesis

Evaluation:
GOAL MET. The client shall have reported pain relief as evidenced by a decrease in pain scale
from 5/10 to 2/10

Problem: Imbalanced Nutrition: less than body requirements related to decrease

absorption of the nutrients as evidenced by loss of weight secondary to Adenocarcinoma
Subjective: None
Objective:
The client manifested:
-Loss of weight (-15kg) on November 14-, 2016.
-Loss of weight (-3kg) on November 22-24, 2016.
-Easy fatigability on November 14, 2016
-Lab result:
Albumin: 32.8 on November 18, 2016
-Potassium:4,14- on November 14, 2016

VS taken as follows:
Temp: 36C
PR: 68 beats per minute
RR: 20 breaths per minute
BP: 100/60 mmHg
Assessment:
Imbalanced Nutrition: less than body requirements related to decrease absorption of the
nutrients as evidenced by loss of weight secondary to Adenocarcinoma
Planning:

After 4 hours of nursing interventions, the client will achieve measurable increase in activity
tolerance as evidenced by reduced fatigue and weakness and vital signs within acceptable limits
during activity.
Interventions:
Assessed weight, age, body mass, strength, and activity and rest levels. Ascertained
stage of disease process and its effects on clients nutritional status.
Inspected oral mucosa.
Evaluated clients appetite.
Weighed frequently.
Encouraged bedrest or limited activity during acute phase of illness.
Recommended rest before meals.
Provided oral hygiene.
Served foods in well ventilated, pleasant surroundings, with unhurried atmosphere
and congenial company.
Avoided that might cause or exacerbate abdominal cramping and flatulencemilk
products, foods high in fiber or fat, alcohol, caffeinated beverages, chocolate,
peppermint, tomatoes, and orange juice.
Promoted client participation in dietary planning as possible.
Encouraged client to verbalize feelings concerning resumption of diet.
Kept client nothing-by-mouth (NPO) status, as indicated.
Resumed or advance diet as indicatedclear liquids progressing to bland, low
residue, and then high-protein, high-calorie, caffeine-free, nonspicy, and low-fiber, as
indicated.
Provided nutritional support, for example: Enteral feedings, such as Ultra Clear Plus
via nasogastric (NG) tube, percutaneous endoscopic gastrostomy (PEG), or J-tube

Evaluation:

GOAL MET. The client shall have achieved measurable increase in activity intolerance as
evidenced by reduced fatigue and weakness and vital signs within acceptable limits during
activity.

Problem: Hyperthermia
Subjective: None
Objective:
The client manifested:
-Flushed skin on November 16, 20, 21, 23
-Warm to touch on November on 16, 20, 21, 23
-Body temperature of more than 37.5C per axilla on November 16, 20, 21, 23
-Pale nail beds and conjunctiva on Novermber 14-24
-Tenderness upon deep palpation on November 14-19
- (+) Mass upon deep palpation on November 14-19

VS taken as follows:
PR=90 bpm
RR=20 cpm
T=38.1 C
BP=110/70 mmHg

Assessment:
Hyperthermia

Planning:
After 4 hours of Nursing interventions, the clients temperature will decrease from 38.1 C to
37.5C.

Interventions:
Monitored and Recorded Vital signs.
Monitored and recorded all sources of fluid loss such as urine, vomiting, diarrhea and

insensible losses.
Provided tepid sponge bath. Do not use alcohol and iced water.
Loosened clients clothing, if tolerable.
Provided cooling blankets.
Encouraged increase in fluid intake.
Promoted a well-ventilated area to client.
Maintained bed rest.
Adjusted and monitored environmental factors like room temperature and bed linens as

indicated.
Administered antipyretics, such as Paracetamol.
Monitored laboratory studies, such as ABGs, electrolytes, cardiac and liver enzymes;
Administered replacement of fluids and electrolytes to support circulating volume and
tissue perfusion.
Provided high-calorie diet, or as indicated by the physician

Evaluation:
GOAL MET. The clients temperature shall have decreased from 38.1C to 37.5C.

Problem: Ineffective tissue perfusion related to abnormal blood profile as evidenced by low
hemoglobin 101g/L (140-175g/L) and hematocrit 0.34 (0.41- 0.50) count
Subjective: None
Objective:
The client manifested:
-Dizziness
-Weakness
-Pale palpebral conjunctiva on Noverber 14-24, 2016
-Lab result: (11-15-16)
-Hemoglobin 101g/L (140-175g/L)
-Hematocrit 0.34 (0.41- 0.50)
-RBC 4.68 (4.52-5.90 x10^12/L)

VS taken as follows:
Temp: 36C
PR: 78 beats per minute
RR: 21 breaths per minute
BP: 110/70 mmHg

Assessment:

Ineffective tissue perfusion related to abnormal blood profile as evidenced by low

hemoglobin 101g/L (140-175g/L) and hematocrit 0.34 (0.41- 0.50) count
Planning:
After 8 hours of nursing intervention, the patient will manifest adequate perfusion as evidenced
by absence of dizziness, weakness and fatigue
Interventions:

Monitored and Recorded Vital signs.

Hemoglobin and hematocrit count monitoring
Examined and documented the presence of pain
Examined GI function, noting anorexia, decreased or absent bowel sounds, nausea or

vomiting, abdominal distension, and constipation.

Checked for pallor, cyanosis, mottling, cool or clammy skin.
Assessed quality of pulse.
Monitored intake, observed changes in urine output. Recorded urine specific gravity as
necessary.
Instructed patient to maintain bedrest
Instructed patient to recognize the signs and symptoms that need to be reported to the

nurse like fatigue, headache

Regulated Intravenous fluid
Provided oxygen therapy as needed
Administered medication (Iron Folic Acid Vit B Complex- Fortifer Fa)
Administered Blood transfusion as ordered (PRBC)

Evaluation:
GOAL MET. The patient shall have manifested adequate perfusion as evidenced by absence of
dizziness, weakness and fatigue.