Millie Larsen Part 1.docx - Documentation Assignments 1 Document your physical assessment findings specific to Millie Larsen Good skin turgor no signs

Millie Larsen Part 1.docx - Documentation Assignments 1...

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Documentation Assignments 1. Document your physical assessment findings specific to Millie Larsen. Good skin turgor, no signs of bruising; no infiltration at the IV site. Head to toe assessment was conducted, nothing pertinent was found. The intake and output were measured and showed the nurse that the patient was dehydrated, but that would soon be corrected as fluid therapy has begun. Lungs clear to auscultation bilaterally, no rales/rhonchi/wheezes noted. Highly elevated blood pressure at 180/ 100, heart rate at 120 bpm and temperature was 98.4 degrees Fahrenheit. The patient is alert, but she is not aware to the time or situation. 2. Document your findings from the Confusion Assessment Method (CAM). In this case the Confusion Assessment Method (CAM) helped the nurse to quickly and precisely identify the presence of delirium. 3. Referring to your feedback log, document the nursing interventions you performed. Administered 650 mg of Acetaminophen orally, 400 mg of Ciprofloxacin IV, 25 mg of Captopril, and 100 mg of Metoprolol orally. Educated the patient and her family on urinary tract infection, medication, and safety. A Confusion Method Assessment method and a Morse fall risk assessment was conducted. Assessed if the patient was aware of the medications she was taking at home and if the patient had any trouble swallowing her medications. 4. Document our report to the physician using the situation-background- assessment- recommendation (SBAR) format. Situation: Patient is an 84- year-old female patient. Admitted with confusion accompanied by her daughter. IV therapy was started in order to increase fluids, correct dehydration, and administer medications. Background: Patient was brought in by her daughter with signs of confusion, delirium caused by a urinary tract infection. The patient has a history of hypertension, high cholesterol and pain in her knees. Patient lives alone but her daughter visits her regularly. Assessment: Highly elevated blood pressure 180/110, heart rate of 120 bpm, temperature of 98.4 degrees Fahrenheit. Good skin turgor, no bruising, wounds, or lesions found. No infiltration at the IV site. Lungs clear to auscultation bilaterally. Pain level of 4 out of 10. The patient is alert, but she is
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