Question

Patient with Primary admission diagnosis is Left knee DJD. Then she has surgery in her legs, she has total knee replacement 5 days ago. She stay in hospital to cover her leg surgery.  she has orthostatic hypotension, A-fib, hypertension, sleep apnea, GERD, memory loss

Base on this patient please answer these question below

what information you want
(S.O.A.P.E. Charting)

Document:

1. Subjective:

2. Objective:

3. Assessment

4. Plan

5. Evaluation

Answer 1

S.O.A.P.E ( Subjective, Objective, Assessment,Plan and Evaluation) charting is a process of documentation of patient informations by the nursing staff so that other healthcare providers can understand and provide care for the patient.

S.O.A.P.E Charting :-

1) Subjective:-

A female patient with primary diagnosis of Left knee DJD( Degenerative Joint Disease) admitted in Surgery department 5 days ago.She has pain, stiffness in left knee.She has medical history of orthostatic hypotension, A.fib., hypertension, Sleep apnea, GERD, memory loss.

2) Objective :- Patient vital signs should be monitor to assess Temperature, Respiratory Rate, Pulse .

Physical examination of Left knee should be done to assess cracking sound, stiffness and locking of joint as seen in case of degenerative joint disease.

3) Assessment:-

X - Ray or MRI of Left knee should be done to assess the level of degenerative changes in left knee .Also other routine blood tests such as Complete blood count( CBC),Kidney Function test(KFT) and Liver function test( LFT) should be done to rule out other clinical conditions before surgery.

4)Plan :- After assessing all reports , total Left knee replacement should be done. Timing monitoring of Blood pressure should be done as patient has history of hypertension and medicine should be provided on time by nurse.She should be given bland diet as she has GERD. A counsellor should be provided to her as she has memory loss problem. Education about exercises should also be given so that she can do after surgery and discharge from hospital.

5) Evaluation:-

Patient vital signs and progress in left knee after surgery should be evaluated time to time .