Shadow Health: Sonia Best – Perioperative Post-Operative
Priority Assessment and Care Plan” ✅
Shadow Health – Sonia Best Perioperative Post-Operative
Priority Assessment
Patient Overview
• Name: Sonia Best
• Status: Post-operative patient (general anesthesia
recovery)
• Setting: Surgical unit, immediate post-op monitoring
, History of Present Illness (HPI)
Sonia Best is a post-operative patient recovering from a
scheduled surgical procedure. She is in the immediate post-
op phase and requires close monitoring of airway, breathing,
circulation, pain level, incision site, and potential
complications (bleeding, hypoxia, infection).
Review of Systems (ROS) – Post-Op Relevant
• General: Reports drowsiness from anesthesia, denies
severe pain when questioned.
• Cardiovascular: No chest pain or palpitations.
• Respiratory: Slightly shallow breathing, denies
shortness of breath.
• GI/GU: No nausea or vomiting at present, Foley catheter
draining clear urine.
• Musculoskeletal: Limited movement due to sedation.
• Skin: Dressing in place, no drainage noted.
• Neuro: Arousable to voice, follows simple commands,
drowsy but oriented ×3.
Physical Examination (Objective)
• Airway: Patent, no stridor.
• Breathing: RR 16, shallow but adequate; O₂ sat 93% on
room air → requires O₂.
Priority Assessment and Care Plan” ✅
Shadow Health – Sonia Best Perioperative Post-Operative
Priority Assessment
Patient Overview
• Name: Sonia Best
• Status: Post-operative patient (general anesthesia
recovery)
• Setting: Surgical unit, immediate post-op monitoring
, History of Present Illness (HPI)
Sonia Best is a post-operative patient recovering from a
scheduled surgical procedure. She is in the immediate post-
op phase and requires close monitoring of airway, breathing,
circulation, pain level, incision site, and potential
complications (bleeding, hypoxia, infection).
Review of Systems (ROS) – Post-Op Relevant
• General: Reports drowsiness from anesthesia, denies
severe pain when questioned.
• Cardiovascular: No chest pain or palpitations.
• Respiratory: Slightly shallow breathing, denies
shortness of breath.
• GI/GU: No nausea or vomiting at present, Foley catheter
draining clear urine.
• Musculoskeletal: Limited movement due to sedation.
• Skin: Dressing in place, no drainage noted.
• Neuro: Arousable to voice, follows simple commands,
drowsy but oriented ×3.
Physical Examination (Objective)
• Airway: Patent, no stridor.
• Breathing: RR 16, shallow but adequate; O₂ sat 93% on
room air → requires O₂.
