MARIELLE CHUA - (Template) SOAPIE Caselet

Name: CHUA, Marielle P.
Date: 06/26/2020
Section: 1C Group #: A09
Notre Dame Hospital

CARRYING-OUT OF DOCTOR’S ORDER
and SOAPIE DOCUMENTATION
Instructions:
1. Review the video lecture on carrying-out the doctor’s order and SOAPIE format of
documentation.
2. Carry-out the doctor’s order by filling-out the following forms:
a. Doctor’s Order
b. Kardex
c. IV Flow Sheet
d. Vital Signs Monitoring Sheet
e. Medication Sheet
f. Medication tickets (label and color)
3. Make nurses notes in SOAPIE format using the form below.
4. Refer to the case scenario.
Situation: On June 23, 2020, at 7:05 AM, you received Mrs. Mila Castro, a 40- year-old
secretary who was admitted to the hospital, at Room G-318 under the service of Dr.
Ignacio. She has the following data:
● Chief complaint of difficulty of breathing
● T = 39.9 0C
● RR = 24 beats per minute
● BP = 120/70 mmHg
● crackles breath sound heard upon auscultation
● expectorating thick, yellow sputum
● flushed skin
● skin warm to touch
● chilling
● labored breathing
● holding chest when coughing
● He expresses, “nahihirapan akong huminga”
The nursing history reveals that Mrs. Castro has colds and cough for several weeks that just
wouldn’t go away. She has smoked one package of cigarettes per day since she was 18 years old.
Chest x-ray confirms pneumonia.
Doctor’s Order:
▪ Plain LR 1 liter to run at 30 gtts/min
▪ Paracetamol 500 mg 1 tab every 6o PRN for fever
▪ Carbocisteine 500 mg 1 cap every 6o for cough
▪ Cefuroxime (Zefam) 185mg q8o IVTT ANST
▪ TPR every 4 hours and record
▪ O2 inhalation 2-3 liters via nasal cannula if dyspneic
▪ TPR q 4 hours and record
▪ Inform attending physician
DOCTOR’S ORDER/NURSES COMPLIANCE SHEET
(AUTHENTICATE ALL ORDERS)
PATIENT’S NAME: Castro, Mila ROOM/WARD:G-318
Notre Dame Hospital
Cotabato City
PHYSICIAN: Dr. Ignacio
C – CARRIED A – ADMINISTERED R – REQUEST MADE E – ENDORSED D – DISCONTINUED
TIME
DATE/ PROGRES
ORDER C A R E D POSTED
TIME S NOTES
SIGNATURE
6/23/20 Plain LR 1 liter to run at / / / MPC
7:05 AM 30 gtts/min
Paracetamol 500mg 1 / / / MPC
tab every 6o PRN for fever

Carbocisteine 500mg 1 / / / MPC
cap every 6o for cough

Cefuroxime (Zefam) / / / MPC
185mg q8o IVTT ANST

O2 inhalation 2-3 liters / / / MPC
via nasal cannula if

dyspneic
TPR q 4o and record / / MPC
Inform attending / / / MPC
physician
Ignacio CHUA, M.
NDU BSN1
06/23/2020 7:30am
Dr. Ignacio
KARDEX
(front)
NURSING NEEDS/TX/ LEVEL RECEIVED

Date Date
Ordered
SPECIAL Ordered
IVF/INCORPORATIONS
7-3 3-11 11-7
ENDORSEMENTS
06/23/2020 O2 inhalation 2-3 liters via 06/23/2020 Plain LR 1 liter to run at 30 800cc
nasal cannula if dyspneic gtts/min
TPR q 4o and record

Inform attending physician
KARDEX
(back)
Date Date
Ordered
DIAGNOSTICS/LABORATORY EXAMS
Ordered
MEDICATIONS
06/23/2020 Paracetamol 500mg 1 tab every 6 o PRN for

fever
Carbocisteine 500mg 1 cap every 6o for cough

Cefuroxime (Zefam) 185mg q8o IVTT ANST
VITAL SIGNS MONITORING SHEET
Notre Dame Hospital
PATIENT’S NAME: Castro, Mila ROOM/WARD: G- 318
Cotabato City
PHYSICIAN:
Dr. Ignacio
SHIFT/
DATE TEMP BP CR/PR RR SIGNATURE
TIME
06/23/2020 7am-3pm 39.9 0C 120/70mmHg 24Bpm
CHUA, M.
NDU BSN1
06/23/2020 7:30am
Notre Dame Hospital and School of Midwifery
Rosary Heights, Cotabato City
PARENTERAL FLUID SHEET
Patient’s Name: Castro, Mila Age/Sex: 40 yrs. Old/Female Room: G-318 Physician: Dr. Ignacio
I. Intravenous Fluids
BOTTLE TIME SIGNATURE/ DATE/TIME SIGNATURE/
DATE SOLUTION VOLUME INCORPORATION
NO. STARTED REMARKS CONS/DISC REMARKS
06/28/2020 1 Plain Lr 1L 7:30am
II. Side Drips

DATE BOTTLE SOLUTION VOLUME INCORPORATION TIME SIGNATURE/ DATE/TIME SIGNATURE/
NO. STARTED REMARKS CONS/DISC REMARKS
III. Blood Transfusion

DATE BAG BLOOD SERIAL TIME STARTED SIGNATURE DATE/TIME SIGNATURE REMARKS
NO. TYPE NO. CONS/DISC

Notre Dame Hospital
AND SCHOOL OF MIDWIFERY
Rosary Heights, Cotabato City
DAILY MEDICATION SHEET
Name: Castro, Mila Room/Ward: G-318 Physician: Dr. Ignacio
DOSAGE DATE: 06/23/2020

ROUTE OF
ADMINISTRATION
FREQUENCY
TIME TIME TIME TIME TIME TIME TIME TIME TIME
Paracetamol 500mg 7-3 8
1 tab every 6o PRN 3-11
11-7
Carbocisteine 500mg 7-3 8
1 cap every 6o 3-11
11-7
Cefuroxime (Zefam) 7-3 8
185mg q8o IVTT ANST 3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
MEDICATION TICKETS
G CASTRO, MILA 06/23/2020

318
Paracetamol 500mg 1 tab every PRN
Chua, Marielle P. / Pegarro, KG
NDU BSN 1 NDU CI

318
Carbocisteine 500mg 1 cap every
NDU BSN 1 NDU CI

318
Cefuroxime (Zefam) 185mg IVTT ANST
NDU BSN 1 NDU CI
NURSES NOTES
PATIENT’S NAME: Castro, Mila

PHYSICIAN: Dr. Ignacio
MEDICINES/
DATE TIME REMARKS (SOAPIE Format)
TREATMENTS
Subjective Data
CC: Difficulty of breathing
The patient verbalized, “nahihirapan akong
huminga.”
06/23/2020 7:05am HPI: 40 yrs. old female with colds and cough for
several weeks.
Habits: She has smoked one pack of cigarettes per
day since she was 18 years old.
Objective Data
VS: Temp. 39.9 0C, RR of 24Bpm, and BP 120/70
mmHg.
Observed:
Skin: flushed skin and warm to touch.
Resp.: expectorating thick, yellow sputum, labored
breathing, and crackles breath sound heard upon
auscultation.
Others: chilling and holding chest when coughing.
Laboratory and Diagnostic Procedures: Chest x-ray
confirms pneumonia.
Assessment
-Ineffective breathing pattern r/t possible infection as
manifested by expectorating thick, yellow sputum,
flushed and warm skin, hyperthermia, and chilling.
- Lack of knowledge about harmful effects of
cigarette smoking.
Plan
-The temperature will decrease to 37.50C after 3
hours.
- The respiratory rate will decrease to 20Bpm after 6
hours.
- The patient has broad knowledge and practice of a
healthy lifestyle before she will discharge.
Interventions
- Monitor vital signs every 1 hour.
- Perform Tepid Sponge Bath until hyperthermia
subsides.
- Administer medications (Paracetamol 500mg,
Carbocisteine 500mg, and Cefuroxime (Zefam)
180mg.) per doctor’s order.
- Encourage patient to increase oral fluid intake.
-Elevate the head of the bed at 20-300 angle.
- Promote healthy lifestyle and cite the risks of
cigarette smoking.
Evaluation
- The patient states, “medyo maayos na ang
pakiramdam ko.”
-Temperature and RR down to normal after expected
time span and patient practiced healthy lifestyle.

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Name: CHUA, Marielle P.

Section: 1C Group #: A09

Notre Dame Hospital

C – CARRIED A – ADMINISTERED R – REQUEST MADE E – ENDORSED D – DISCONTINUED

tab every 6o PRN for fever

cap every 6o for cough

185mg q8o IVTT ANST

via nasal cannula if

Inform attending / / / MPC

NURSING NEEDS/TX/ LEVEL RECEIVED

TPR q 4o and record

06/23/2020 Paracetamol 500mg 1 tab every 6 o PRN for

Carbocisteine 500mg 1 cap every 6o for cough

PARENTERAL FLUID SHEET

II. Side Drips

NO. STARTED REMARKS CONS/DISC REMARKS

III. Blood Transfusion

NO. TYPE NO. CONS/DISC

DAILY MEDICATION SHEET

Name: Castro, Mila Room/Ward: G-318 Physician: Dr. Ignacio

DOSAGE DATE: 06/23/2020

G CASTRO, MILA 06/23/2020

G CASTRO, MILA 06/23/2020

G CASTRO, MILA 06/23/2020

PATIENT’S NAME: Castro, Mila

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