SOAPIE Patient Name: Ms. Brown Diagnosis: Urinary

SOAPIE Patient Name: Ms. Brown Diagnosis: Urinary Tract Infection Case Study: Plan – Detailed explanation of the healthcare plan to address the issue of concern. Holistic approach to care identified (ensure recommendations aren’t only focused on pharmacological interventions). Intervention and Evaluation – Brief description surrounding the intervention provided and how it was tolerated by the client. Determine if the intervention was successful and identify the indicators that support this. S – An 85-year old patient admitted to a medical unit with a suspected urinary tract infection (UTI). Has a history of congestive heart failure, total hysterectomy, total knee replacement and situational depression when her husband passed away. Experiencing concerns of falling into a chair, dribbling while going into the bathroom, fatigue and not being hungry for a week. O – Height: 5’5″ Weight: 160 pounds Vital signs: Blood Pressure: 140/88 Pulse: 90 bpm Respiratory Rate: 22 Temperature: 36.1 °C A – Tested for urinalysis and CBC with differential but was recommended for further evaluation and treatment in a hospital.

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