Nursing Assignment: SOAPIE Framework, Nursing Diagnosis, and Goals of Care

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
Name of the Student:
Name of the University:
Author Note:

1NURSING ASSIGNMENT
Response a:
Admission Summary using the SOAPIE Framework: The SOAPIE framework works on
developing an understanding based on subjective data, objective data, assessment, plan,
intervention and evaluation (Lenthall et al., 2015)
S Subjective Data  The client is an
unconscious state
because of sustaining
a major head injury
on account of a fall
from the escalator
 Presence of soft
tissue injuries around
the neck region
 Presence of
laceration on arms
and legs
 Deep wound on the
outer side of the
lower right leg
 No presence of
fractured bone in the
skull as evident from
CT scan and X-ray
O Objective Data  GCS score
equivalent to 9
 Pulse range between
80-92 minutes per
minute
 Responding to
painful stimuli,
unconscious
 Recorded respiration
rate, 18-20
respirations per
minute
 Recorded blood
pressure: 180/120
mm Hg
 Presence of red areas
on sacrum and heels
 Oxygen saturation
recorded to be 97%
within the room air
 FWT revealed
increase in glucose
level

2NURSING ASSIGNMENT
 The deep wound on
lower right leg is
seen to be inflamed
and oozing fluid
discharge
 Urine output is
recorded to be higher
than 30mls/hour
A Assessment The laceration and would
marks are seen to improve,
however the wound on the
right leg is seen to worsen
and shows no improvement.
The blood pressure is
elevated and the GCS score
9 indicates moderate brain
injury. The glucose level in
the blood is high and the
body temperature is slightly
elevated. The respiratory
rate as well as the pulse rate
is recorded to be fairly
normal. The blood pressure
level needs to be controlled
and the blood glucose level
also needs to be controlled
on an immediate basis.
P Plan A change is needed in the
plan prioritizing the control
of blood pressure and the
glucose level in the blood.
The wound on the upper
right leg must also be
treated on a priority basis so
as to speed up the process of
recovery. Pain score
assessment must be carried
out on an hourly basis.
I Intervention Interventions used for the
patient comprised of the
administration of 5%
dextrose and antibiotic
intravenously.
Administration of
Benazepril would
effectively help in
normalising the blood
pressure.
E Evaluation The client is moderately
febrile and is showing signs