Documenting the patient’s assessment and nursing care plan using
Problem Oriented Medical Record
Problem-oriented medical record applies the SOAP, SOAPIE or
SOAPIER method for care planning.
Applying SOAPIE in the given case:
Subjective data : recently quit smoking, on medication for
diabetes and hypertension.
Objective data: patient was admitted for worsening of asthma and
chronic bronchitis. patient is 20 lb overweight
Assessment: wheezes in lungs, +2 pitting edema on ankles; skin
is pale. Patient is anorexic, not eaten in 3 days.
| Plan |
Intervention |
Evaluation |
|
To improve the airway clearance
(Ineffective airway clearance related to narrowing of airways,
increased pulmonary secretions as evidenced by wheezing sound)
|
- Assess the vital signs to identify the deviation from
normal
- Assess for anxiety as it can worsen the breathing pattern
- Assess for intensity of wheezing as it is a result of
bronchospasm. Diminishing wheezing and indistinct breath sounds are
signs of impending respiratory failure.
- Monitor oxygen saturation and assess for cyanosis that
indicates low O2 saturation
- Advice to have periods of rest in between activities
- Elevate the head end of bed to improve lung expansion
- Encourage deep breathing and coughing exercises to loosen and
remove the secretions
- Teach pursed lip breathing techniques as it will improve the
breathing pattern.
|
Patient may manifest effective removal and
lung secretions and improved breathing pattern during
evaluation. |
|
To relieve fluid imbalance
(Fluid volume excess related to compromised regulatory
mechanisms as evidenced by edema and increase in body weight)
|
- Monitor body weight regularly to identify the progress of
edema.
- Closely monitor intake and output
- Monitor BP and heart rate to identify arrhythmias
- Assess for lung crackles to identify fluid accumulation in
lungs.
- Limit sodium intake as it facilitates fluid retention
- Elevate the lower limbs to promote venous return and reduce
edema
- Reposition the patient every 2 hours. It reduces the chances of
dependent edema
|
Patient may manifest reduction in edema
over the ankle and other body parts. |
|
To improve the nutritional status and maintain optimum body
weight
(Imbalanced nutrition related to dyspnea as evidenced by lack of
interest in food, overweight)
|
- Assess the dietary pattern and difficulty with eating.
Increased sputum production, dyspnea and medications causes
anorexia.
- Assess bowel sounds. Decreased sounds indicates constipation
and decreased gastric motility associated with decreased intake of
food and fluids and hypoxemia
- Offer mouth care frequently to remove the unpleasant taste
following expectoration or medication intake.
- Advice intake of a balanced diet to maintain the muscle mass
and meet energy requirement
- Advice to avoid spicy and hot and cold foods as it may
precipitate episodes of cough
- Encourage small and frequent diet.
- Teach weight reduction strategies to maintain optimum body
weight.
|
Patient may manifest with improved dietary
intake and understanding of importance of weight reduction. |
|
Advantages |
Disadvantages |
|
Source-oriented/narrative |
- It gives information on patient status in a chronological
order
- It includes all the steps of nursing process
|
- Includes all the findings (normal & abnormal) making it
difficult to sort out relevant information at a particular
time.
- It is time consuming and requires large amount of manual
work.
|
| Problem-oriented medical
record |
- Enables comprehensive care by focusing on patient problems
- Applies and promotes problem solving approach.
- Facilitates continuity of care as well as communication by
recording only relevant information.
|
- Difficult to identify changing trends in patient's status
- Requires large number of flow sheets that may cause
fragmentation of data.
|
| Focus charting |
- Focus on patient from a positive perspective
- It is similar to POMR but changes the problem which is negative
to focus which is positive
- It is compatible with nursing process
- Shortens the time for charting
|
- Inadequate data base may lead to missing of patient's problems
details
- It doesn't focus only on nursing diagnosis and expected outcome
charting technique.
|
| Charting by
exception |
- Is based on set standards of patient care services provided and
needs met with a normal response
- Focus mainly on patient data and changing trends in patient's
status
- Requires less time for narration
- Avoids the chances of duplication of charting.
|
- Needs specific standards and protocols for application
- Requires training of the staff with pre set protocols and
techniques
- Sometimes important data may also get omitted
|
| Case management |
- Ensures continuity of care
- It is a holistic technique
- Provides coordinated care for individual patients
- Helps to manage financial expenditure
|
- Case management activities are diverse and complex that are
challenging
- Requires extensive training for effective implementation
|