Focused Exam: Mobility (Part 2 of 2)
Medical Surgical Nursing: Promoting Wellness in the Older Adult - April 2020, nurs201-la_nurs201_202004spii_5
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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
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4/24/2020 Focused Exam: Mobility | In Progress Attempt | Shadow Health
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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
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