ACTUAL SOAPIE

S - “Hindi ako nagbaBT kase wala pang pera”- as verbalized by the patientO - Received on bed on supine position conscious and coherent, with intact

and unsoaked incision dressing, (-) breast engorgement, urine (1), (-)BM, unsoaked vagial/perineal pads with moderate amount of lochia serosa, (-)Homan’s sign, ambulatory, pale buccal mucosa and conjunctiva, hgb count (77), hct (0.33), with initial vital signs taken as follows: BP- 120/80 mmHg, PR-83 bpm, RR-26 bpm, Temp.-36.4 oC.

A - Altered Tissue Perfusion r/t decrease hgb(77), hct(0.33) countsP - After 2o of nursing intervention, the patient will verbalize understanding

of the condition, treatment/therapy regimen, and will demonstrate behavioral changes to improve circulation.

I - Assessed for physical manifestations of anemia- Assessed for factors that could precipitate to anemia such as bleeding on incision site, excessive lochia and diet.- Assessed diet/food preference- Encouraged to increase intake of food rich in iron such as animal liver & green & leafy vegetables when in DAT status- Instructed to watch for sign of bleeding on incision site (soaked dressing) and increase in lochia- Instructed compliance to oral iron supplement intake- administered due medication

E - Patient verbalized understanding of condition and therapeutic regimen and demonstrated behavioral changes to improve circulation

S - “Eku migalo masakit kasi, maghilab ya ing tiyan ku dati, tatakut naku”- as verbalized by the patient

O - Received on bed on supine position conscious and coherent, with intact and unsoaked incision dressing, (-) breast engorgement, urine (1), (-)BM, unsoaked vagial/perineal pads with moderate amount of lochia serosa, (-)Homan’s sign, ambulatory, pale buccal mucosa and conjunctiva, hgb count (77), hct (0.33), with initial vital signs taken as follows: BP- 160/90 mmHg, PR-90 bpm, RR-23 bpm, Temp.-36.4oC.

A - Impaired Physical Mobility r/t pain and discomfort secondary to episodes of uterine contractions: preterm labor

P - After 2 hours of nursing intervention, the patient will display increase in activity level and will verbalize understanding to maintain safety.

I - Monitored V/S- Assessed for episodes of preterm uterine contraction- Assessed for degree of discomfort that limits patient’s movements- Assisted in performing ADL

- Instructed to increase food rich in calorie sch as fruits, vegetables, rice, bread, etc. to regain energy- Instructed patient to perform ADL as tolerated and gently