NUNP_6540_WEEK_3_SOAP_NOTE_.docx Week 3: SOAP Note Walden University

NUNP_6540_WEEK_3_SOAP_NOTE_.docx    Week 3: SOAP Note            Walden University               NRNP 6540      2  The purpose of this weeks assignment is the discussion of a geriatric patient presenting to the hospital. The patient takes at least five prescription and over the counter medications.  This assignment will include the Subjective, Objective, Assessment and Plan (SOAP) for the patient, which will include documenting suggestions, education to care giver and a reflection statement.   Subjective Data  Chief Complaint: “My leftknee hurts”    History of Present Illness (HPI)  M.M is a 90-year-old female presenting with a history of left knee pain.   ï‚·Onset – Chronic joint pain that has been present and getting worse for months  ï‚·Location: Left knee  ï‚·Duration: comes and goes over the past 6 months  ï‚·Character: Dull, aching pain including joint stiffness.  M.M rates the pain on scale 1-10, a 3 being mild, and as high as 10 being the worst pain.    ï‚·Aggravating factors: This pain varies depending on her activity level.  Pain is worse in the mornings upon waking up.  ï‚·Alleviating factors: M.M. takes Tylenol for arthritis, which improves some of the pain and stiffness throughout the day.  ï‚·Radiation: Joint pain that sometimes travels to her back and her hands, and it becomes generalized.