Subjective [PDF]

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SOAPIE Subjective



Mrs. A is a 28-year-old female with a diagnosis of placenta previa. The patient crying and confused. She complained of fear when she experienced bleeding. She stated, “Natatakot ako baka dahil sa pagdugo, mawala ang anak ko.”



Objective



Today, the patient’s vital signs were as follows:  BP: 110/80 mmHg  PR: 110 bpm  RR: 21 bpm She is crying and at the same time trembling. The patient is also experiencing muscle tension and palpitations.



Assessment



The patient’s status is improving, and she is being taught about her condition. Little by little, she was able to concentrate and tried to remain calm. Currently, the patient has a Fear r/t threat to maternal and/or fetal survival secondary to excessive blood loss.



Planning



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Intervention



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Evaluation



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After 6-8 hours, the client will be able to: identify her fears and client will exhibit decreased fear and will be evaluated at the end of the shift. maintain a good vital signs. Made the patient listened to fetal heart sounds. Provided adequate time for discussion and a calm environment. Provided accurate and honest information about client’s condition and expected plan of care. Assisted client and family to identify specific fears. Assisted client and family to identify ways to cope with fears. Taught relaxation techniques, creative visualization, etc.



After 7 hours, client identified her fears and methods to cope with each by applying the relaxation techniques.  Client reported a decrease in fearfulness when she told the nurse that, “I fully understand my situation and I am thankful that my fear of losing my child lessened.”  Client was able to have a stable vital signs AEB  BP: 120/80  PR: 90 bpm  RR: 19 bpm