Write a nurse’s note using SOAPIE (subjective, objective, assessment, planning, intervention, evaluation) for the following case study.
Use creativity, prediction, intellectual integrity, and information seeking to add appropriate nursing assessments that you would conduct (and invent the findings) and write a nursing note for the priority problem. Include patient safety.
Assure accuracy, clarity, and adherence to appropriate standards of care.
Identify the patient problem (NANDA or describe the problem) and include the etiology.
Elizabeth Taylor is an 82 year old patient admitted to the hospital 8 days ago for treatment of Acute Lymphocytic Leukemia. She has received her second cycle of chemotherapy and is complaining of weakness, decreased appetite, nausea and vomiting. She has been placed on fall precautions. At 7:15 AM today 3/7/12 she was found lying on the floor next to her bed. Pt stated that she was trying to get to the bathroom and became weak and fell. She is A&O x3 and moves all extremities equally. She has a small abrasion to her left forehead.
As the oncoming nursing you will evaluate this patient and write a note regarding her s/p fall. Use creativity and write a note with likely assessment findings and appropriate interventions for this problem. Remember to predict possible injury that this patient may experience related to her medical condition and the fall and include in your assessment data.
Use language from the attached document.
