Our Services

Get 15% Discount on your First Order

[rank_math_breadcrumb]

HEALTH ASSESSMENT

Name: Jacob Edmonds

Age: 88 years

Provider: S. Jones MD

Allergies: NKDA

Code Status: DNR

Admit Wt: 189 lbs (85.7 kg)

BMI: 27.1

NURSING ASSESSMENT & NOTES

1/17 1800

Neurological Assessment: PERRLA, refused to answer questions, usual shuffling gait with the walker, sometimes refusing to use a walker (poor balance noted without a walker), refuses to squeeze hands, mumbling words that are not understandable, occasional yelling and combativeness, agitated and restless.

1/18 0300

Nursing Note: The client was found ambulating in his room in the dark at 0220 without his walker. The UAP provided the walker, and the client shouted, “I don’t need that!” and continued to walk toward his door and out of the room. With assistance, the client was directed to the recliner with feet raised.

1/18 0430

Nursing Note: Found sitting on the floor near his recliner with the recliner still in the reclined position. No injuries were observed. Denies pain. VS WNL. Unable to explain the details of how he got there. Restless and agitated, hitting at the nurse. Pajama bottoms wet, refused to be changed. Able to get him back to bed with a 3 person assist. Agency policy implemented for frequent neuro checks per protocol.

1/18 0710

Nursing Note: Alert and oriented to person. Speech is clear. Strength in all four limbs is strong. Eyes PERRLA. Able to follow simple commands. Became agitated and began yelling at the UAP asked about needing to void. The nurse could direct into the bathroom, where he voided dark, cloudy, foul-smelling urine. He denied pain when urinating. Agreeable to come to the dining room for breakfast. He was using a walker.

1/18 1445

Nursing Note: Taking oral fluids and urinating. Urine is less cloudy than earlier today but is still dark and has an odor. Afebrile. He was assisted to bathroom 4x this shift. Up in the hall, he was using a walker. Pleasant with staff and less agitated but refused to go to bed for a nap after lunch. The nursing staff has been successful in redirecting when necessary.

VITAL SIGN TREND

Date

Temp

HR

RR

BP

SpO2

O2

1/18 0530

97.8 °F
(36.5 °C)

78

20

129/84

98%

RA

1/18 0710

97.8 °F
(36.5 °C)

77

20

127/80

98%

RA

intake and output

Date

Intake Source & Amount

Output Source & Amount

1/18 0730

incontinent

1/18 0800

150 mL

1/18 0900

200 mL

1/18 1015

240 mL

1/18 1030

100 mL

1/18 1200

50 mL

1/18 1230

300 mL

1/18 1330

135 mL

1/18 1400

150mL

1/18 1445

50 mL

PROVIDER PRESCRIPTIONS & NOTES

1/18 0930

Plan of Care:
Goal:
 The client will demonstrate signs of adequate hydration with increased urine output.

Actions:

· Encourage fluids, targeting 100 mL/hour

· Toilet hourly for output measurement

· Monitor urine output and characteristics of urine

COLLABORATIVE CARE

1/17 1430

Physical Therapy Note: Mr. Edmonds easily directed, occasionally losing focus but then redirected. Orientation X 1, sometimes mentioning the facility and time of year. Discussed the use of the walker to assist in ambulation and reinforced how to use it. Demonstrated technique. Cautioned that his balance is poor and that he should use the walker to avoid falling. Became teary when discussing his wife, who died many years ago, and his need to be in a facility. Expressed gratitude, stating, “This is a nice place. I don’t have a purpose right now.” Allowed to ventilate as he told stories about his past. Escorted to the day room and appeared to be watching a football game on television.

1/18 0530

Medical History:

·
Major neurocognitive disorder with behavioral disturbance

·
Benign prostatic hyperplasia

·
Hypertension

·
Hyperlipidemia

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

NUR 620

1. Reply from Daniela Barbeito Depression Case Summary of the Clinical Case Ms. Z is a 28-year-old assistant store manager who appears sad after she had a breakup one month ago. On the subjective, she complains that she has low mood, oversleeping, fatigue despite long sleep duration, lack of concentration

NUR 504 Module 4 Discussion

Module 4 Discussion   The Homeless Patient Evaluation & Management Plan The nurse practitioner (NP) is working at a health clinic in a homeless shelter during the early evening. A 48-year-old African American man approaches the practitioner and asks to have his blood pressure taken, saying that he has not

Clinical module 4 discussion

Module 4 Discussion   Weekly Clinical Experience 4 Describe your clinical experience for this week. · Did you face any challenges, any success? If so, what were they? (identifying the needed studies needed for the patients’ symptoms) · Describe the assessment of a patient, detailing the signs and symptoms (S&S),

Interprofessional Education

see attachment The purpose of this assignment is to evaluate how interprofessional education has evolved within the health care environment to support a more team-based approach to patient-centered health care. In a paper of 500-750 words, address the following points: 1. Define interprofessional education, explain how it was developed, and discuss the goals

Children and Families Clinicals Discussion 4

Weekly Clinical Experience 4 Describe your clinical experience for this week with a 10-month-old male with conjunctivitis · Did you face any challenges, any success? If so, what were they? · Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least

Children and Family Discussion 4

Approaches to Disease Management: Dermatologic Disorder Discuss Impetigo in pediatrics, a dermatologic disorder, and its treatment modalities. Submission Instructions: · Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

see attachment

MUST BE ORIGINAL WORK. 4-6 pages long. APA format. 3-5 scholarly resources from the last 5 years. On topic below.  Teaching Plan Paper (30 points) APA Paper  • Target Population: Adolescent boy ages 13-17 pertaining to mental health, 14 participants  o Who is your target audience? – include age of

NUR 620

 Patient Care After studying Module 1: Lecture Materials & Resources, discuss the following: The unlawful restraint of a patient can be a legal pitfall for the PMHNP.  K.W. was found eating hamburgers out of a Mcdonald’s dumpster and drinking water from an old water hose.  She had not taken a bath

HW

Professional Goal and Objectives: (SMART) · Professional goals and objectives are related to this course’s clinical rotation (practicum).  · Please note that the SMART goals and objectives you submit must be professional in nature. · During your clinical practicum, you will have the opportunity to work side-by-side with an expert (RN

Discussion

Module 5 Assignment PICOT Question Assignment effective strategies to decrease pediatric obesity in primary care settings.  This is certainly an area/challenge that FNPs are constantly faced with in primary care and particularly with some specific cultures or ethnic groups

Week 3 discu

General Instructions: Conflict is common in healthcare settings. Common team sources of conflict include hierarchical relationships, authority differentials, poor communication, negative or disruptive behaviors, and multigenerational interprofessional teams.    Include the following sections:  Application of Course Knowledge: Answer all questions/criteria with explanations and detail.  Describe a conflict you have encountered in your nursing

NUR509W4

DISCUSSION: The nurse practitioner (NP) is working at a health clinic in a homeless shelter during the early evening. A 48-year-old African American man approaches the practitioner and asks to have his blood pressure taken, saying that he has not had it checked “in a while”. The man appears to

NUR509CL 4

DISCUSSION: Describe your clinical experience for this week. · Did you face any challenges, any success? If so, what were they? · Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales. (CASE: R shoulder

nurse sam

Anemia Classification Instructions: For each of the scenarios below, identify the following: 1. Type of anemia a. Folate Deficiency b. Anemia of Inflammation c. Iron Deficiency Anemia d. Vitamin B12 Deficiency e. Thalassemia 2. Classification of anemia a. Microcytic-hypochromic b. Macrocytic-normochromic c. Normocytic-normochromic 3. After identifying the type and class,

nursing

To Prepare: Review resources about contextual factors. Consider how contextual factors will impact your advocacy priority.  By Day 3 of Week 4 Post a response detailing the following:  Which contextual factors will promote getting your advocacy priority on the agenda?  Which contextual factors might work against it?

nursing

To prepare: Search databases in the Walden Library and locate a peer-reviewed article from the last 5 years that uses a randomized controlled trial study design. The subject of the study may be any topic professionally relevant or interesting to your practice. You may not select an article already posted by

AMP450Effective Leadership Approaches and Models in Health Care

Effective leadership is integral to quality health care. Following global crisis, crucial leadership skills are needed to not only navigate stressful situations with the collaboration of the interprofessional health care team but also to lead with innovation and find solutions for the future.

AMP450Topic 1 DQ 2

Describe two unique challenges that health care leaders face and how leadership theories can address these challenges.