Psychiatric Nursing: SOAPIE and POR

Documentation in Psychiatric Nursing Practice

• Problem-oriented recording (POR) follows the SOAPIE format
• POR uses a list of patient problems as its basis
• In nursing, POR identifies a nursing diagnosis on a written plan of care
• Nursing interventions are described for each POR

SOAPIE

• S: Subjective data from the patient, family, or other sources
• O: Objective data from direct observation, including physiological measurements or behavioral responses
• A: Assessment of the nurse's interpretation of the subjective and objective data
• P: Plan for actions or treatments
  • This may be omitted if the plan is explained in the nursing care plan and no changes are expected
• I: Intervention, or the nursing actions carried out
• E: Evaluation of the problem after the nursing intervention - Evaluation may be optional if not immediately possible

Problem-Oriented Recording (POR)

• POR is a structured documentation method Focuses on specific patient problems
• POR ensures clear and systematic patient care
• SOAPIE expands traditional SOAP by adding intervention and Evaluation
• Expanded tracking evaluates nursing action effectiveness

Example of SOAPIE Documentation

• Patient Name: Maria Santos
• Patient Age: 52
• Diagnosis: Major Depressive Disorder with Anxiety
• Date/Time: January 19, 2025, 10:00 AM
• Problem: Anxiety and Sleep Disturbances

SOAPIE Example Breakdown

• S: The patient reports restlessness, inability to sleep, racing thoughts, and feeling overwhelmed
• O: The patient appears anxious with frequent hand-wringing and pressured speech - Patient reports 3-4 hours of sleep per night during the past week - Vital signs include BP of 130/85 mmHg and HR of 98 bpm
• A: Generalized Anxiety Disorder (GAD) symptoms persist and contribute to sleep disturbances
• P: Education is to be provided, adherence to SSRI is vital, schedule a follow up in one week
• I: The patient was guided in a 5-minute deep breathing exercise - Written materials on progressive muscle relaxation and sleep hygiene were given - Reinforced the importance of medication adherence
• E: Patient verbalized knowledge of relaxation techniques, demonstrated breathing exercises, and commitment to sleep hygiene practices - Patient will monitor sleep patterns and anxiety symptoms at the next visit

Narrative Recording

• A descriptive account of an event, told from a particular point of view
• Provides precise detail and is chronological
• Lengthy and time-consuming

Narrative Recording as Documentation

• It provides a comprehensive record of the patient's condition over time
• Captures observations, actions, and response in sequence
• Unlike structured formats like SOAPIE, narrative recording flows as a story

Narrative Charting Entry Example

• Patient Name: John Dela Cruz
• Patient Age: 35
• Diagnosis: Schizophrenia – Acute Episode
• Date/Time: January 19, 2025, 9:30 AM
• 9:30 AM, Patient pacing the unit with tense facial expressions and clenched fists, saying, "They are watching me..."
• 9:45 AM, Nurse guided the patient to a quiet room with encouraged deep breathing and offered 2mg Risperidone.

Later Interventions and Observations

• 10:00 AM, the patient agrees to medication after calm reassurance
• Stimulation tools were provided
• 10:30 AM, reassessment shows lower tension and patient engaging with staff, remained suspicion

Narrative Recording - Key Features

• It is chronological and Detailed — Provides a real-time sequence of events
• Descriptive — Captures behaviors, responses, and interventions thoroughly
• Flexible — Allows for documentation without structural limitations
• Comprehensive — Useful for complex patient cases

Narrative Recording - Advantages

• It provides a complete story of the patient's experience
• Allows for expressive documentation with subtle observations
• Useful in psychiatric nursing, where patient behavior changes dynamically

Narrative Recording - Disadvantages

• It can be time-consuming compared to structured formats
• Risk of inconsistencies if details are omitted
• Harder to retrieve specific information than problem-oriented formats like SOAPIE

Appropriate Use

• Use for behavioral observations (hallucinations, aggression, paranoia)
• Crisis management documentation of emergencies
• Medication refusal/acceptance monitoring
• Detail-oriented therapeutic communication responses to document

Summary

• Narrative recording values providing a detailed and contextual account
• Account include the patient’s mental state, behaviors, and responses to interventions
• Used strategically alongside structured formats for efficient documentation

Process Recording

• Used to teach nursing students to understand interaction
• Conversation between nurse and patient in special format

Process Recording - Key Components

• Document observations, thoughts, conversations
• Student nurses asked to analyze communication
• Determine therapeutic and non-theraputic techniques used
• Nursing professor analyzes students interactions
• Helps students recognize difficulty

Process Recording - Analysis

• Involves reviewing difficult patient encounters
• Requires adjusting communication techniques
• Self-reflection helps with growing strengths and areas of improvement

Process Recording Technique

• Process recording is a verbal and non-verbal analysis
• Used for psychiatric nursing education
• Allows nurses to learn effective communication techniques
• This is used for improving patient communication skills

Process Recording - Example

• Patient Name: Anna Reyes
• Age: 28
• Diagnosis: Generalized Anxiety Disorder (GAD)
• January 19, 2025 1:00pm

Nurse statement

• Analysis communication techniques. Analysis is open ended
• Pt responds saying she is feeling overwhelmed Pt seems heard and understood
• Pt say something can help, but doesn't think anything will
• Pt ok with trying something small

Analysis

• Here the patient feels heard and understood by restating the concern
• Helps to elaborate and explore feelings further
• Helps the patient recognize effective coping mechanism
• Supports decision making
• Increases to small manageable steps towards improvement

Process Recording - Key Features

• Focus on communication (verbal and non-verbal)
• Analyze techniques
• Helps nurses assess effectiveness

Process Recording - Advantages

• Enhances therapeutic skills
• Helps assess ineffective techniques
• Improves interaction

Process Recording - Disadvantages

• Transcription dialogue with detailed analysis can be time consuming
• Mainly used for self reflection rather than clinical charting
• Possible change to responses

Therapeutic Modalities: Biophysical/Somatic Interventions

• Treatments using physical or physiological interventions to improve behaviors

Physical Therapies: Electroconvulsive Therapy (ECT)

• Ugo Cerletti and Luciano Bini introduced ECT in 1938
• Electrodes on head deliver electrical impulse leading ti brain seizure
• Brain chemistry is stimulated to correct chemical imbalance of depression
• Clients receive three times weekly for 6-15 treatments
• Depressive symptoms improve with 6 treatments
• Benefit achieved in 12-15 treatments

ECT: Indications

• Use in select groups for depression, such as clients who do not respond to antidepressants
• Suicidal patients where safety is first priority
• Pregnant women and those safe from medications to use ECT are indicated
• Acute Schizophrenia
• Catalonia
• organic brain disorder like people with psychosis or Alzheimer's

ECT Preparations

• Similar preparations to other surgical procedures
• NPO after midnight
• Removal of fingernail polish
• Voids before the procedure
• IV for meds administration
• Injection of short-acting anesthetic
• relaxes muscles to reduce outward signs of seizure

ECT Treatment

• Electrodes deliver side to side to electrical stimulation
• Brain activity is monitored
• Oxygen given and breathing assisted
• Gag returns

ECT Potential effects

• mild confusion
• headache
• tired
• symptoms may grand mal seizure
• memory impairment

Psychopharmacology: Antipsychotic Agents/Neuroleptics

• Used from the 1950s antipsychotics work for schiophrenia and help with anxiety, insomnia and behaviours
• This can be done using dopamine receptors D2,D3,D4 Antipsychotic agents: blocking
• This reduces nausea, induces sedation and increases weight

Categories for Antipsychotic Agents

• Phenothiazines
• Chlorpromazine
• Perphenazine
• Fluphenazine
• Thioridazine
• Mesoridazine
• Trifluoperazine

Categories for Non-Phenothiazines

• Butyrophenones
• Haloperidol
• Droperidol
• Dibenzazepines
• Loxapine
• Dihydroindolones
• Molindone Thioxanthines
• Thiothixene
• Atypical
• Clozapine
• Paliperidone
• Iloperidone
• Asenapine

Atypical MOA

• Weakly block D2 receptors
• Inhibits serotonin reuptake
• Improves treatment for schipophrenia

Classification for Fluphenazine

• Neuroleptic piperaizine phenothiazine

Dosage for Fluphenazine

• 205-10 mg daily
• Administered IM/SQ , single does of 12.5-25
• Deconate injection requires 10 mg/daily

MOA Fluphenazine

• Blocks dopamine controlling psychotic symptoms

Haloperidol and Haloperidol Deconate

Classification: Antipsychotic

• Initial: 0.5-2 mg BID/TID, max 100 mg/da

MOA Haloperidol

• Alters dopamine
• Treats psychoses
• Treats schizophrenia, Tourette syndrome

Side effects Haloperidol

• Weight change, blurred vision, rashes

Classification for Ariprazole

• Non-phenothiazine

Nursing Interventions for Non and Phentothiazine

• Monitor vital
• Swallowed Medication
• Avoid Skin contact

Nursing Intervention Teaching

• Full effects may take 6 weeks or longer as a long-term intervention.
• Interactions can occur do not take anti psychotics with alcohol
• Smoking affectiveness.
• Family Planning Discuss with doctor family planning issues

Anxiety Medications

• Anxiety can be reduced with alparozam or chlordiazepoxide
• Lorazepam is benzodiazepine treats anxiety levels

MOA Anxiety Medications

• Enhance GABA
• Buspirone lowers anxiety

Route

• Anxiety levels can be reached orally

Side Effects

• Dizziness, blurred vision and uncoordination are common side effects.
• Dizziness
• Headache

Patient Teaching for Anxiety Medications

Avoid alcohol to avoid sedation

Antidepressants

• Medication can reduce depression MOA TCA’s: blocking norepinephrine and serotonin reuptake in the brain

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Effects to block reuptake of serotonin will enhance levels in the brain for mood effect

Side Effects for Selective Serotonin Reuptake Inhibitors (SSRIs)

• Suicidal thoughts
• sexual dysfunction decrease due to less dopamine levels
• seratonin noepinephrine ru uptake for major depression is done with Cymbalta
• Fluoxetine treats depression symptoms, by blocking seratonin reuptake
• Nursing Interventions for depression is monitor vital signs. Weight gain is important weekly
• Mental stabilizer for bipolar Can be done with Lithium and valproic acid

MOA Lithium

• Modifies in both
• muscles and nerves
• Enchance seretonin levels Lithium has possible metallic taste thirst.

Nursing Interventions for Lithium

• lithium is checked and drug toxicity is checked within safe levels
• check kidney functions
  • lithium is monitored in the kidney

Lithium Teachings

• The most common is to take and follow up lithium blood levels, stoping at a sudden time causes relapsing
• Avoid driving with unsafe lithium levels
• Limit caffeine to ensure blood levels are good for normal sodium uptake and lithium for electrolyte balance
• Patients in need for stimulant with atomoxitine or methylphenidate Those with adhd show a strong cns for adhd

Other helpful interventions for mental health : supportive physocotherapy

• nurse and patient therapy

*group therapy can be helpful with anxiety

Goal for group therapy

• Gaining inspiration
• Teaching therapy (draw)
• Music therapy (play instruments)
• Bibliotherapy
• Dance

Goals for Raising therapy

• Occupation
• improve interaction
• decrease pressure Remotivation (45 minutes for an hour)

MOA Mental Health

• improve isolation behavior
• provide meaningful conversion
• Mental patients have an objective
• Encourage communications-express
• Use familiar topics

Remotivation Goals Cont

• Remotivation includes a friendly environment
• Providing an easier setting
• Understanding people thoughts
• Conclude with encouragement

Mental Health: Patients

These Patients with schizophrenia and dementia show motivagion

• Talk about
• science

Assertive training

• Helping with the life situation with goals to have more control
• Include ‘I” questions

Example : The”I” question

Feel angry when you’re turn to the talk

• 30 minutes of time without interruptions

Stress therapy:

• stress reduces attitude
• accept controll is not possible
• be assertive
• do the daily routine tasks with meditation

Behavior Modification

• Reducing irrational fears
• Gradulat exposure
• Enjoy that is not available that includes that the client enjoy

Negative therapy

• Negative re enforcements and
• Reinforcements for bad behavior
• Cognitive behavior structure, is an easier way for other to change the way of thinking for the thoughts.

Therapy for Surroundings

• The structure and effect changes
• Patient is easy adapts to relationship for setting

Play therapy

• For bad behaviour

The Goals For the mind: PsychoSocial Support

• The goal is to improve the individual well being and have the right mindset with the correct well being.
• Some spiritual interventions include activities with counselling and focus
• Religious interventions with prayer

MOA Psycho

• Medication that is integrative or complimentary
• non traditional