SOAP DOCUMENTATION ASSIGNMENT

Name: Shamyah Joseph Date: 1/22/2021

Mr. Ron Brown is a 71 year old gentleman with Type 1 diabetes admitted to hospital for treatment of an
ulcer on his right heel. Diane was assigned to Mr. Brown and Diane also provided nursing care to him
yesterday. Mr. Brown was alert and oriented to person, place and time. He normally had no problems
with ambulation. Currently due to right heel ulcer, his gait is unsteady. Mr. Brown wears glasses to read
and drive and he has no hearing deficits. He lives alone. Mr. Brown’s discharge plan is to return to his
apartment. Patient’s vital signs today were as follows: BP 162/82, Pulse 64 and regular, Respirations 16
per minute and pulse ox 98% on room air. His lungs are clear. Bowel sounds are active and patient had a
bowel movement x 2 today, both soft. Continent of urine. Skin color is pale. 2+ non-pitting edema noted
in right feet. Mr. Brown is currently taking Insulin for his diabetes. Pt is scheduled for wound nurse
consultation. Physician order Hgb AC1 levels in morning. Patient was placed on bedrest for 24 hours.

Subjective Data (Subjective refers to things the patient can tell you, and often includes pain level and
feelings or concerns. It can also refer to things a patient’s family members tell you.):

Mr. Brown is a 71-year-old man with type 1 diabetes. He is a very alert person, place, and time-oriented
man. He is wearing glasses to read, and he can drive. There are no deficiencies at the hearing. Mr.
Brown lives on his own. Normally, he has no problems with an ambulation, but he has an ulcer on his
right heel. Mr. Brown will be released shortly for full recovery in his apartment.

Objective Data (Objective refers to hard data you collect regarding the patient. This can include vital
signs, laboratory results, observable signs and symptoms, and your physical assessment findings):

Mr. Brown vital shows that his BP 162/82 indicates that he has stage 2 hypertension. Pulse 64 and
regular, respiration 16 per minute and pulse ox 98% in room air. His lungs are noticeably clear. Mr.
Brown's bowel is active and has bowel movements twice today, both of which are soft. It has a urinary
diversion continent. His skin color is pale, but 2+ non-pitting edema on his right legs. Mr. Brown is
currently taking insulin for diabetes mellitus. Pt is scheduled for consultation with the wound nurse.
Physicians order the Hgb AC1 levels in the morning. Mr. Brown have been placed on bedrest for 24
hours.

Assessment (Assessment refers to your overall interpretation of the subjective and assessment. Is the
patient improved since admission? Are there new issues that you are observing that need to be
addressed? All of these things belong in the assessment.) :

Mr. Brown has not fully recovered since his admission. He has stage 2 hypertension, which should be
monitored closely, particularly due to his history of diabetes. He can easily become a type 2 diabetes
patient if his BP continues to rise, causing a heart attack or stroke. Mr. Brown has a 2+ non-pitting
edema on his right foot. This can lead to heart failure or kidney failure and slow down the healing
process of his ulcer.
Plan (Plan refers to the patient’s plan of care. How is the medical team addressing the patient’s health
problems? Are there upcoming tests or blood draws? Is the patient on medications to treat a problem
that you are monitoring a response to? These are examples that fall under the plan.) :

He was placed on insulin for his diabetes, which would help to regulate his blood sugar and increase his
blood pressure. Pt is scheduled for consultation with the wound nurse. Physicians order the Hgb AC1
levels in the morning. Mr. Brown have been placed on bedrest for 24 hours.

Interventions (Interventions refers to the things we are doing for the patient. Examples of
intervention can include treatments and medications, as well as education provided to the patient on
your shift):

Mr. Brown's insulin intake will need to be monitored closely. Scheduled a PT with a consultation of Mr.
Brian ulcer on the wound. Check with your doctor to order Hgb AC1 levels for any abnormalities in the
morning. Observe the patient on his bedrest for 24 hours, if any other problems occur or subsize.