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SOAP for Case Study

Subjective data

The subjective data entails the information the patient provides. In the case above, the patient complains of dizziness upon ambulation which may indicate low blood pressure or orthostatic hypotension. The patient also notes that their blood pressure is lower than their baseline values. 

Objective data

Objective data encompasses the assessment data taken through inspection, palpation, percussion and auscultation. Vital signs to include temperature, pulse rate, respirations and blood pressure offer insights to the general well-being of the patient and any deviations from normal physiology. The patient is unable to walk following the surgery

Assessment

The patient requires time postoperatively to recover and regain their limb function. From the assessment data, the patient has impaired physical mobility that translates to self-care deficit. The dizziness puts the patient at a risk of syncope and trauma following falls.  Impaired skin integrity at the operation site.

Plan

Close monitoring of the patient to minimize risk of trauma following falls

Provide the patient with a walking frame to encourage early ambulation to reduce complications and joint stiffness

Monitor vital signs which may provide indicators in case of change in the status of the patient

Close monitoring of the patient’s blood pressure especially following their complaints of dizziness to determine the etiology

Perform passive joint exercise followed by active exercises such as physical therapy to preserve joint function

Avoid heavy physical exercises especially knee pivotal physical activities until the full role of the knee is regained with complete Range of Movement (ROM).