Question

Mrs. Norma James is an 86-year-old female admitted to the unit after having a stroke that has left her with a left-sided paralysis. She has been in bed for several weeks. At 0815h when you greet Mrs. James she states "my stomach is hurting and I haven't had a bowel movement for 3 days." On examination Mrs. James's abdomen is firm and distended. Nursing records indicate she has not had a bowel movement recorded for 3 days despite being given lactulose yesterday. At 0820h you administer a glycerin suppository to Mrs. James as per her medical directive. At 0915h you follow up with Mrs. James and her abdomen is soft and no longer distended. She reports having had a large bowel movement and feeling much better.

Write a note documenting care, using the SOAPIE format, based on the provided scenario. Ensure you are using the proper formatting.

Answer 1

SOAPIE ;;;; Subjective, Objective, Assessment, Plan, Implementation, Evaluation.

Subjective= the pt complains of stomuch hurting and no bowel movement since 3 days

Objective= on examination I found the abdomen is distended and firm

Assessment = I assessed the pt and her condition by a manual examination like palpation and percussion, on palpation the abdomen was firm and distended , on percussion the sound coming back was dull suggesting something is there .

Plan = I plan to give suppository to relieve her distension

Intervention= I gave the glycerine enema to the pt and told to take deep breath and remain in position for at least 15 mints

Evaluation= the pt says that she feels comfortable now no distension at all.