NURSING ASSESSMENT & NOTES |
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4/5 1030 |
Name: Gloria Cox Age: 92 years Provider: U. Beaker MD Allergies: NKDA Code Status: Full Code Admit Wt: 85 lbs (38.5 kg) BMI: 17.2 Neurologic/Cognitive: Alert, oriented to name only. Pupils 4 mm PERRLA. Can follow commands, utilized wheelchair due to fatigue, grips moderate and equal. Cardiovascular: S1/S2 with occasional PVCs per monitor. Respiratory: Tachypnea, decreased breath sounds with scattered wheezes in all fields, productive cough, greenish tint. Gastrointestinal: Abd soft with active bowel sounds. Last bowel movement was 2 days ago per son. Genitourinary: Client is incontinent of urine, recently started about a month ago. Musculoskeletal: Weakness, using wheelchair. Was walking independently until about a month ago. Integumentary: Skin is dry, per son, the client will not get in the shower. |
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4/5 1105 |
Nursing Note: Respiratory therapist unavailable to administer breathing treatment, administered by RN. Lungs before treatment with decreased breath sounds in all fields, wheezes noted, and cough is dry. |
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4/5 1120 |
Nursing Note: Lung assessment – increased air movement in upper fields, slight wheezes noted, bases remain decreased. Productive moist cough sputum sample obtained, slight greenish tint. |
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4/5 1150 |
Nursing Note: Respiratory therapist at bedside to obtain ABGs. |
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VITAL SIGN TREND |
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Date |
Temp |
HR |
RR |
BP |
SpO2 |
O2 |
4/5 1015 |
99.6 °F |
100 |
24 |
110/62 |
90% |
2L/NC |
4/5 1105 |
99.4 °F |
106 |
22 |
116/68 |
94% |
2L/NC |
PROVIDER PRESCRIPTIONS & NOTES |
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4/5 1100 |
Prescriptions: · Albuterol and Ipratropium combination treatment (DuoNeb) x 1 treatment · Arterial Blood Gas · Urinalysis · 2 view chest x-ray · Sputum sample |
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COLLABORATIVE CARE |
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4/5 1015 |
Urgent Care Note: Client accompanied by son with report of increasing dyspnea for the past two weeks. Was 1 pack/day smoker x 50 years, quit 10 years ago. History of COPD first diagnosed last year. Progressive weight loss over the past 6 months. Occasional use of O2 at 2L via NC until the past 2 weeks, now continuous. Productive cough for the last 6 months with thick, occasional green sputum production. Using her albuterol MDI, 2 puffs every 2 hours, for the past 14 days. Has not been getting relief from MDI for the 2 weeks. The client’s son has the MDI with him. No doses remaining. “I didn’t know there was a counter. I wonder how long it has been empty.” “My mom has been more confused the last couple of weeks. She was always sharp, and now she doesn’t remember if she took her medicine. She has been calling my wife by my sister’s name.” |
Journal Response Module 7
Reflecting on your experiences and readings Reflecting on your experiences and readings, discuss methods of effective communication that you will employ to promote the collaboration and active engagement of various professionals and participants in the planning and implementation of a quality improvement project. Journal Response Expectations each week. Each short-answer