Question

how will i make a documentation objective on a patient who underwent a vetral hernia repair with component seperation and biologic mesh to achieve definitive abdominal wall closure and what methods can i use in documenting objective findings as a nurse?

Answer 1

Method :-SOAP format can be used in documenting objective findings

Subjective

Patient`s subjective respose to the medical intervention

Patients`s changes in active or passive limitation

Objective

a)Status update

b) Intervention

Summary of intervention that were performed.

c) Micturation, voiding of feces shall be monitered in terms of

• Frequency
• Duration
• Intensity

so as to look up on early complications -Urinary tract infection, paralytic ileus, seroma, pneumonia

Assessment

• Pain
• Wound healing

Plan

Prevent wound infection

Recurrence rate high, therefore modalities to control obesity

control smoking, have medication for diabetes ( if found diabetic)