A nurse is using the SOAP format to document the progress notes of a client who has hypertension.

The nurse needs to select all that apply when writing the plan of care for this client.

Which of the following are appropriate components of the plan in the SOAP format?

These are appropriate components of the plan in the SOAP format.SOAP stands forSubjective, Objective, Assessment, Planand it is a form of written documentation many healthcare professions use to record a patient or client interaction.

• Ais correct because monitoring blood pressure and pulse every 4 hours is an objective and measurable intervention that can help evaluate the patient’s condition and response to treatment.

• Bis correct because educating the client about dietary sodium restriction is an intervention that can help prevent or reduce hypertension and its complications.

• Dis correct because evaluating the effectiveness of antihypertensive medication is an intervention that can help assess the patient’s progress and adjust the treatment plan accordingly.

• Cis wrong because assessing for signs of orthostatic hypotension is not an intervention, but an observation that belongs to the objective section of the SOAP note.

• Eis wrong because identifying the risk factors for developing hypertension is not an intervention, but an assessment that belongs to the assessment section of the SOAP note.

Normal ranges for blood pressure are<120/80 mmHgfor normal,120-129/<80 mmHgfor elevated,130-139/80-89 mmHgfor stage 1 hypertension, and≥140/≥90 mmHgfor stage 2 hypertension.Normal ranges for pulse rate are60-100 beats per minutefor adults.

The client’s oxygen saturation level has improved from 88% to 95% after receiving oxygen therapy for 24 hours.

This is an example of an evaluation entry in the PIE documentation system because it describes the outcome of the intervention (oxygen therapy) for the problem (low oxygen saturation level) using objective data (percentage).

Other choices are wrong because:.

• Choice A: The client has been coughing less frequently and reports feeling less short of breath.

This is an example of an intervention entry because it describes the actions taken by the nurse to address the problem (coughing and shortness of breath).

• Choice B: The client has a productive cough with yellowish sputum and crackles in the lower lobes of both lungs.

This is an example of a problem entry because it identifies the signs and symptoms of the health condition (pneumonia).

• Choice D: The client will maintain a normal oxygen saturation level of at least 92% with supplemental oxygen as needed.

This is an example of a plan entry because it states the expected outcome or goal for the problem (low oxygen saturation level).

The PIE documentation system is a process-oriented system that uses the acronym PIE to document theProblem,Intervention, andEvaluation of the patient’s progress.It integrates care planning with progress notes and does not separate the patient from the environmental influences.The normal oxygen saturation level for healthy adults is between 95% and 100%.