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.

Observed facial grimace and guarding of the abdomen.

This is an example of a data entry in the DAR format because it describes the objective and subjective information that the nurse collected from the client.Data entries can include vital signs, physical assessment findings, laboratory results, and client statements.

Choice A is wrong because it is an example of an action entry in the DAR format.Action entries describe the nursing interventions that the nurse performed to address the client’s problem or need.

For example, administering medication, providing education, or applying a dressing.

Choice B is wrong because it is an example of a response entry in the DAR format.Response entries describe the client’s reaction or outcome to the nursing interventions.

For example, reporting pain relief, expressing satisfaction, or showing improvement.

Choice D is wrong because it is also an example of an action entry in the DAR format.

It describes another nursing intervention that the nurse performed to help the client cope with pain.

The DAR format is a type of focus charting that helps nurses document problems identified in the client care plan.

It stands for data, action, and response.Some nurses may use the F-DAR format, which adds a focus component to provide a clearer context and prioritization of the client’s needs.The focus can be a nursing diagnosis, a change in condition, a symptom, or an event.