SIMULATION Current Health Status Client Background She was admitted 2 days ago after being difficult to Biographical Data arouse from a nap. A CT...
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Please read the following information from the report and answer the remaining question below.

Report from the night shift nurse: Mrs. Theodora Phillips is a 75-year-old female. She and her husband are well known in the local community as philanthropists. The local media have been calling the hospital for updates on the situation. We are not to provide any information regarding her situation. She was admitted 2 days ago after being difficult to arouse from a nap. A CT scan revealed a chronic subdural hematoma. The follow-up CT scan this morning showed some improvement. Patient recalled falling and hitting head on coffee table over 2 weeks prior. She has some old ecchymosis to her right temporal region from the fall. She is a 2-ppd smoker, drinks socially. She has not been to her PCP in over 10 years. Neurologically she has improved from her original GCS of 12 to a score of 14 today. She requires frequent orientation to place and time. She initially was lethargic on admission but now can hardly sleep at all. She is pleasant and is able to ambulate with assistance. She does have ataxia, tremors, and there is apparent mild left-sided hemiparesis, so her husband/daughter helps with feeding her. Her right pupil is slightly larger than the left. Her chest has crackles to mid and lower lobes with a productive cough. She sats at 92% on 2 L nasal cannula. RR is in the 20s. She is on a nicotine patch. She requests cigarettes frequently and has to be reminded that she is in the hospital on oxygen. She has normal heart sounds, no peripheral edema, and cap refill is <3 sec. She is on telemetry, and reports indicate that she is in a sinus rhythm to a sinus tachycardia with a rate of 80-110. Her BP is 130-180/80-90. We are treating her blood pressures with labetolol prn. I last gave that to her 2 hr ago. She has bowel sounds and her abdomen is soft and flat. She is cachectic in appearance. She had a BM yesterday. She doesn't have much of an appetite and claims the food is "horrible." She is on a mechanical soft diet. She had some nausea last evening and vomited. She got Dimenhydrinate at 2100. She has a Foley in for clear yellow urine. I&O was 2100/1900 mL. She has a peripheral saline lock that flushes well. Her lab work from this morning is WNL except her Hgb is low (7.8), her magnesium is low (1.7), and liver enzymes are elevated. We just got an order to treat her magnesium but it has not arrived from pharmacy yet. Mrs. Theodora Phillips is in her bed awaiting breakfast. Her husband/daughter is with her in the room.


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1) Based on the information provided please explain what are the relevant data from the report? What are relevant data from other sources? What data is missing? What are the sources for missing data? What data requires follow up?




2) After reviewing the report and clients background, Describe each of the following upon initial focused assessment.

General appearance:


Integumentary:


HEENT:


Respiratory:


CV:


Breasts:


Abdominal:


Neuro:


Musculoskeletal:


Reproductive:


Additional:


3) Based on the information provided, identify 3 priority nursing diagnosis. For each nursing diagnosis provide assessment data, priority problem, intervention, expected patient outcomes, and which interventions can be delegated to the nursing assistant.

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SIMULATION Current Health Status Client Background She was admitted 2 days ago after being difficult to Biographical Data arouse from a nap. A CT scan revealed a chronic subdural Age: 75 hematoma, The follow-up CT scan this morning showed Gender: female some improvement. Patient recalled falling and hitting Height: 5 ft 5 in head on coffee table over 2 weeks prior. She has some old Weight: 110 lb ecchymosis to her right temporal region from the fall over 2 weeks ago. Cultural Considerations History Language: English Psychosocial history Ethnicity: European heritage Nationality: American Social support: lives with husband/ daughter Culture; no significant cultural considerations identified States social drinker only Smokes 2 ppd Demographic Past health history Marital status; married Patient states she is &quot;perfectly healthy&quot; Educational level: college Has not been to PCP in over 10 years Religion: Presbyterian Family history Occupation: philanthropist Mother deceased from liver failure Father deceased from lung cancer Admission Sheet Name: Theodora Phillips Age: 75 Gender: Female Marital Status: Married Educational Level: College Religion: Presbyterian Ethnicity: European heritage Nationality: American Language: English Occupation: Philanthropist

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