Sonia Best Subjective Data, Sonia Best SOAP Note Example and Sonia Best Perioperative Shadow Health

Sonia Best Subjective Data

Sonia Best Subjective Data is perioperative shadow health subjective data on Sonia Best, a 56-year-old female recovering from a left below-the-knee amputation due to a non-healing diabetic foot ulcer, reporting manageable pain rated at 3/10.

Sonia Best expresses significant anxiety about post-amputation mobility and independence, stating concerns about managing at home despite maintaining good cognitive function and overall stability.

Sonia Best complex medical history includes Type II Diabetes Mellitus, peripheral vascular disease, and coronary artery disease, all requiring comprehensive medication management and lifestyle modifications.

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Sonia Best SOAP Note Documentation

Patient: Sonia Best
Age: 56 years old
Gender: Female
Date of Assessment: [Current Date]
Time: [Current Time]
Unit: Medical-Surgical Floor, Shadow General Hospital
Nurse: [Student Name], SN
Instructor: [Instructor Name], RN, MSN

Sonia Best SUBJECTIVE DATA – Best perioperative shadow health subjective

Chief Complaint

Ms. Best is a 56-year-old female admitted for recovery following a left below-the-knee amputation secondary to a non-healing diabetic foot ulcer. The patient reports experiencing pain rated at 3/10 on a numerical pain scale in her left leg. She describes the pain as intermittent and manageable with current interventions.

Current Symptoms and Concerns

The patient states she is “doing fine” overall but expresses significant concerns about adapting to life after amputation. She verbalized anxiety about future mobility and independence, stating, “I’m worried about how I’ll manage at home.” Ms. Best demonstrates good cognitive function, remaining alert and oriented to person, place, time, and situation throughout the assessment.

The patient denies experiencing fever, chills, or fatigue. She reports no chest pain, palpitations, cough, or shortness of breath. There are no complaints of nausea, vomiting, or diarrhea. She indicates adequate sleep patterns and appetite since admission.

Past Medical History

Ms. Best has a significant medical history, including:

• Type II Diabetes Mellitus: Diagnosed approximately 15 years ago, managed with oral medications and insulin therapy
• Peripheral Vascular Disease (PVD): Contributing factor to current amputation
• Coronary Artery Disease (CAD): Managed with medication therapy
• Hypercholesterolemia: Currently treated with statin therapy

Surgical History

The patient underwent a successful left below-the-knee amputation yesterday due to a non-healing diabetic foot ulcer that failed to respond to conservative treatment measures. The surgical procedure was performed without complications.

Current Medications

• Dapagliflozin 10 mg PO every morning (SGLT2 inhibitor for diabetes management)
• Glargine insulin 25 units subcutaneously every evening (long-acting insulin)
• Insulin aspart sliding scale subcutaneously before meals and at bedtime:
  • Blood glucose 150-199 mg/dL: 3 units
  • Blood glucose 200-249 mg/dL: 5 units
  • Blood glucose 250-299 mg/dL: 7 units
  • Blood glucose 300-349 mg/dL: 9 units
  • Blood glucose >350 mg/dL: Call physician for dosage
• Aspirin 81 mg PO daily (cardioprotective therapy)
• Rosuvastatin 20 mg PO daily (statin therapy for hypercholesterolemia)

Allergies

NKDA – No known drug allergies. Patient denies all environmental and food allergies.

Social History

Ms. Best lives alone in a single-story home but maintains a strong support system consisting of family members who live nearby. She has arranged to stay with a family member during her initial recovery period. The patient has a significant tobacco history, smoking half a pack of cigarettes daily for 36 years. However, she successfully quit smoking six months ago in preparation for surgery.

Her alcohol consumption is minimal, reporting wine intake 1-2 times per week with 1-2 drinks per sitting. Her last alcoholic drink was six days ago. The patient also reports medical marijuana use, consuming one edible dose monthly for the past couple of months to manage chronic pain. Her last marijuana use was three weeks ago.

Ms. Best is currently unemployed but previously worked in retail management. She completed high school and has adequate health literacy, demonstrating understanding of her medical conditions and treatment plans.

OBJECTIVE DATA

Vital Signs

• Temperature: 37.1°C (98.8°F) – within normal limits
• Blood Pressure: 134/80 mmHg – slightly elevated (Stage 1 hypertension range)
• Heart Rate: 90 beats per minute – regular rhythm, within normal limits
• Respiratory Rate: 20 breaths per minute – within normal limits
• Oxygen Saturation: 99% on room air – excellent oxygenation

Physical Assessment

General Appearance

Ms. Best appears comfortable and in no acute distress. She is alert, oriented, and cooperative during the assessment. Her affect is appropriate but shows mild anxiety when discussing future care needs. She maintains good eye contact and responds appropriately to questions.

Cardiovascular System

Heart sounds S1 and S2 are audible and distinct with no extra sounds, murmurs, or gallops detected. Regular rhythm with a rate of 90 beats per minute. No peripheral edema noted in the right lower extremity. Capillary refill time is less than 3 seconds in the right foot. Blood pressure is slightly elevated at 134/80 mmHg, consistent with her history of hypertension.

Respiratory System

Lung sounds are clear bilaterally in all lung fields with no adventitious sounds such as crackles, wheezes, or rhonchi. Respiratory effort is unlabored with symmetrical chest expansion. No use of accessory muscles observed. The patient demonstrates effective coughing ability.

Gastrointestinal System

Bowel sounds are present and normal in all four quadrants. Abdomen is soft, non-tender, and non-distended. The patient reports normal bowel movements and denies any gastrointestinal discomfort. No nausea or vomiting reported.

Neurological System

Patient is alert and oriented to person, place, time, and situation (A&O x4). Speech is clear and appropriate. Pupil response is equal, round, and reactive to light and accommodation (PERRLA). Upper extremity strength is 5/5 bilaterally. No signs of confusion or cognitive impairment noted.

Integumentary System

Skin is warm, dry, and intact with normal turgor. No signs of breakdown or pressure areas noted in accessible areas. Skin color is appropriate for ethnicity with no cyanosis or pallor observed.

Surgical Site Assessment

The left lower extremity amputation site shows appropriate post-operative appearance. Surgical markings are present and verified against the medical record and patient identification. The site is covered with appropriate dressing that remains clean, dry, and intact. No visible drainage, erythema, or signs of infection noted. The amputation was performed at the below-knee level as planned.

Pain Assessment

Patient rates current pain as 3/10 on a numerical rating scale. She describes the pain as intermittent, aching in quality, located in the left leg (phantom limb sensation). Pain is currently well-controlled with prescribed analgesics. Patient reports pain is worse with position changes and better with rest and medication.

Laboratory and Diagnostic Data

Note: Recent laboratory results and diagnostic imaging reports should be included here when available from the medical record.

ASSESSMENT

Nursing Diagnoses (Priority Order)

1. Acute Pain related to surgical amputation as evidenced by patient report of 3/10 pain in left leg and protective behaviors

• Supporting Data: Patient reports pain level of 3/10, recent surgical amputation, requests pain medication
• Expected Outcome: Patient will report pain level of 2/10 or less within 24 hours

2. Disturbed Body Image related to loss of limb as evidenced by patient verbalization of concerns about life after amputation

• Supporting Data: Patient expresses anxiety about future mobility and independence, recent amputation
• Expected Outcome: Patient will verbalize acceptance of altered body image within one week

3. Risk for Infection related to surgical incision and diabetes mellitus

• Supporting Data: Recent surgical procedure, history of diabetes, immunocompromised state
• Expected Outcome: Patient will remain free from signs and symptoms of infection

4. Impaired Physical Mobility related to amputation as evidenced by altered gait and need for assistive devices

• Supporting Data: Recent below-knee amputation, will require prosthetic fitting and gait training
• Expected Outcome: Patient will demonstrate safe mobility with assistive devices within 48 hours

5. Knowledge Deficit related to post-amputation care as evidenced by patient questions about home management

• Supporting Data: Patient expresses concerns about home management, new diagnosis requiring lifestyle changes
• Expected Outcome: Patient will demonstrate understanding of post-amputation care within 48 hours

Medical Diagnoses

1. Post-operative status following left below-the-knee amputation secondary to non-healing diabetic foot ulcer – currently stable
2. Type II Diabetes Mellitus – stable on current medication regimen, requiring continued glucose monitoring
3. Stage 1 Hypertension – requires monitoring and possible medication adjustment
4. Peripheral Vascular Disease – ongoing condition requiring management
5. Coronary Artery Disease – stable on current cardiac medications

PLAN

Nursing Interventions

Pain Management

• Assess pain level using 0-10 numerical rating scale every 2-4 hours and PRN
• Administer prescribed analgesics as ordered and evaluate effectiveness
• Implement non-pharmacological comfort measures including positioning, relaxation techniques, and distraction
• Educate patient on phantom limb sensation and management strategies
• Monitor for signs of breakthrough pain and notify physician if pain exceeds 5/10

Surgical Site Care

• Assess amputation site every shift for signs of infection (redness, swelling, drainage, increased warmth)
• Maintain sterile technique during dressing changes per physician orders
• Monitor and document wound healing progress
• Educate patient and family on proper wound care techniques
• Ensure proper positioning to prevent contractures

Infection Prevention

• Monitor vital signs every 4 hours with attention to temperature trends
• Assess white blood cell count and other infection markers as ordered
• Maintain strict hand hygiene and standard precautions
• Educate patient on signs and symptoms of infection to report
• Ensure adequate nutrition to support healing

Mobility and Rehabilitation

• Consult physical therapy for mobility assessment and rehabilitation planning
• Encourage early mobilization as tolerated and per physician orders
• Assist with transfers and ambulation using appropriate safety measures
• Begin patient education regarding future prosthetic use
• Prevent complications of immobility through range of motion exercises

Psychosocial Support

• Provide emotional support and therapeutic communication
• Allow patient to express concerns and feelings about amputation
• Arrange social work consultation for coping strategies and community resources
• Consider referral to support groups for amputees
• Include family in education and support sessions

Diabetes Management

• Monitor blood glucose levels as per sliding scale protocol
• Administer insulin as ordered and document blood glucose responses
• Coordinate with dietitian for nutritional counseling
• Educate on importance of glucose control for wound healing
• Monitor for signs and symptoms of hyperglycemia or hypoglycemia

Patient and Family Education

• Provide comprehensive education on post-amputation care
• Discuss prosthetic options and rehabilitation timeline
• Reinforce diabetes management strategies
• Educate on signs and symptoms requiring immediate medical attention
• Provide written educational materials for reference

Interdisciplinary Collaboration

Physician Communication

• Notify physician immediately if:
  • Pain level exceeds 5/10 despite interventions
  • Signs of surgical site infection develop
  • Vital signs indicate instability
  • Blood glucose levels become difficult to control
  • Patient develops complications

Consultations Required

• Social Work: Assessment for psychosocial support, coping strategies, and community resource coordination
• Physical Therapy: Mobility assessment, strength evaluation, and rehabilitation planning
• Occupational Therapy: Activities of daily living assessment and adaptive equipment needs
• Dietitian: Nutritional assessment and diabetes management optimization
• Prosthetist: Future prosthetic evaluation and fitting (when appropriate)

Discharge Planning Considerations

• Coordinate with family support system for post-discharge care arrangements
• Arrange home health services for wound care and diabetes management
• Schedule follow-up appointments with surgeon, primary care physician, and specialists
• Ensure patient has necessary medical equipment and supplies
• Verify insurance coverage for prosthetic devices and rehabilitation services

Monitoring and Evaluation

• Reassess nursing diagnoses and interventions every 8 hours
• Document patient progress toward expected outcomes
• Modify care plan based on patient response and changing needs
• Ensure continuity of care through comprehensive shift reports
• Evaluate effectiveness of pain management and adjust as needed

EVALUATION

The patient’s current condition is stable with manageable pain levels and no immediate complications. Ms. Best demonstrates good understanding of her medical conditions but requires continued education and support regarding post-amputation care. Her strong family support system and previous motivation to quit smoking indicate good potential for successful rehabilitation.

Priority areas for continued focus include pain management, infection prevention, emotional support for body image adaptation, and comprehensive discharge planning to ensure successful transition to home care.

Nurse Signature: _________________________, SN
Date: _________________
Time: _________________
Instructor Review: _________________________, RN, MSN

References:

• Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier.
• Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (2021). NANDA International nursing diagnoses: Definitions and classification 2021-2023 (12th ed.). Thieme.
• Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of nursing (10th ed.). Elsevier.