Shadow Health Focused Exam: Mobility (SBAR)

Focused Exam: Mobility (Part 2 of 2) Medical Surgical Nursing: Promoting Wellness in the Older Adult - April 2020, nurs201-la_nurs201_202004spii_5 Return to Assignment (/assignments/328177/) Reflections Activity Desc ...

Focused Exam: Mobility (Part 2 of 2) Medical Surgical Nursing: Promoting Wellness in the Older Adult - April 2020, nurs201-la_nurs201_202004spii_5 Return to Assignment (/assignments/328177/) Reflections Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning proces This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the p Documentation Review SBAR Student Response Model Documentation 1. Situation pain in leg for few days and calf is swollen red. pain two days ago in abdomen. pain in lower left calf. fell when getting out car and was dizzy. no allergies. past medical: hypertension, osteoarthritis, and enlarged prostate. past surgical:adbominal hernia at 58 years old. medication: Metoprolol 50mg tablet 1/2 tablet by mouth daily fill date: 04/20 expiration: 06/20 family history: father died from colon cancer, mother had possible passed from haeart failure. uncontrolled urine due to enlarged prostate, and hypotension lead to fall. otherwise normal functional status. Mr. Hall is an 80-year-old White male admitted from the E today with the diagnosis of DVT, fall, and dizziness. 2. Background uncontrolled urine due to enlarged prostate, and hypotension lead to fall. otherwise normal functional status. Metoprolol 50mg tablet 1/2 tablet by mouth daily fill date: 04/20 adbominal hernia at 58 years old. expiration: 06/20 hypertension, osteoarthritis, and enlarged prostate. no allergies. Mr. Hall has a history of HTN, BPH, osteoarthritis and occasional heartburn. He was admitted through the ER at PM because of a fall this morning. He was lying in his gara until his daughter found him. His treatment plans related to issue include labs, urinalysis, intravenous fluids, pain medications and anticoagulation. 3. Assessment pt. able to do muhc on his own such as dressing, eating, and occassionally uses a cane. uncontrolled urine due to enlarged prostate, and hypotension lead to fall. otherwise normal functional status. pt. stated no abuse at home or of any kind of elder abuse. alert and oriented x4. Mr. Hall is alert and oriented x 4. He complains of pain and rates it currently as a 2/10 in his left leg. He was given acetaminophen 325 mg P.O. for pain at 1 PM, and oxycod 5 mg P.O. for pain at 2 PM, with mild relief of pain. His left is edematous and warm to touch. His left leg, hip, and kne are bruised. Denies that he hit his head, no signs of active bleeding. He gets dizzy when he stands. He has an unste gait and uses a cane to walk. His urine is amber, incontine urine at times. Heart sounds are RRR, breath sounds are in all lobes. His IV site is without redness or infiltration. He given 5 mg Warfarin once his INR lab came back. Upon re of his home meds that he brought with him, it was discove he was taking 50 mg of metoprolol instead of 25 mg. The medicine bottle instructs him to cut the pills in half, but he not do this. Nursing Admitting... SBAR This study source was downloaded by 100000831988016 from CourseHero.com on 05-07-2022 09:54:42 GMT -05:00 https://www.coursehero.com/file/60489835/Focused-Exam-Mobility-SBARpdf/ 4/24/2020 Focused Exam: Mobility | In Progress Attempt | Shadow Health https://westcoast.shadowhealth.com/assignment_attempts/6690339 2/2 Submit Attem Student Response Model Documentation 4. Recommendation high fall risk. pain in leg for few days and calf is swollen red manage with pain medication and monitor the edema. Based on my assessment, I recommend the following thin Contact provider to inform him that he was taking a double dose of metoprolol at home. Monitor INR. Contact attending to order additional anticoagulant therap such as enoxaparin SC injection. Teach patient how to administer prescribed out-patient anticoagulant therapies. Order a nutrition consult, the patient lost 10 pounds in the 6 months. Follow up with PT/OT for mobility assessment and recommendations for home. Follow up with case management to see his needs for assistance at home. Teach about fall prevention in the home