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 the patient information and today as the nurse do assessment and write the

(S.O.A.P.E. Charting)

Base on this patient please answer these question below (Please typing )

(S.O.A.P.E. Charting)

Document:

1. Subjective:

2. Objective:

3. Assessment

4. Plan

5. Evaluation

Answer 1

U patient worth por mary admission ciagnoris left knee DID : S. 0. 4. P. E Lesce biective, Objective, Guessment; plant. Excheation PE Charling is a process of documentation of hent informations by the Nursing Staff so that other health care for salient S.D.A.P.E Charling :- mnm Seebeclire - ~ A Jemale patient with primary diagnosis of left knee DID [De generative Joint Disease] admitted in Siergery department 5 days ago. - she has pain stiffness in left knee. she has medical history of orthostatic hypotension. 1 fob, hypertension , sleep apnea, GERD memory loss. Objective in pakent vital signs should be monitor to asses Temperature Respiratory Rale pulse physical examination of left knee should be done a scanned to assess Cracking sound, Stifness and locking - CS CamScannot degenerative Joont ctisease ..

* Assessment : - 06 X-Ray (6) MRI of left knee should be done to accesses the level of degeneralite changes in left knec. Also other meline blood tests such as complete. blood Corent (CBC) kidney function lest(KET) and CLFT) Liver function Test should be done to rule our other chnical conditionds before Surgery plan - Atley assessing all reports total left knee replacement should be clone Tpming monitoring of blood presscere should be done as palient has history of hypertension. and medicine should be provided to her as She has memory fost problem. Eduation about execrise should also be given so that she can do after surgery and discharge from hospital. cente Etalealim - pakent vital Signs and process in left knee . after surgery should be exaluated time to Scanned with me CamScanne fine :