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NR 341 week 8

NURSING ASSESSMENT & NOTES

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.

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.

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.

4/5 1150 

Nursing Note: Respiratory therapist at bedside to obtain ABGs.

VITAL SIGN TREND

Date

Temp

HR

RR

BP

SpO2

O2

4/5 1015

99.6 °F
(37.6 °C)

100

24

110/62

90%

2L/NC

4/5 1105

99.4 °F
(37.4 °C)

106

22

116/68

94%

2L/NC

PROVIDER PRESCRIPTIONS & NOTES

4/5 1100

Prescriptions:

· Albuterol and Ipratropium combination treatment (DuoNeb) x 1 treatment

· Arterial Blood Gas

· Urinalysis

· 2 view chest x-ray

· Sputum sample

COLLABORATIVE CARE

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.”

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