NURS 201 Focused Exam Cognition Notes Shadow Health

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Nursing Admitting Note Student Response Model Documentation Chief Complaint (No Documentation Made) Patient came in with a pounding headache and reports some recent memory loss. Orientation (No Do... cumentation Made) Alert and Oriented x 4 History of Present Illness (No Documentation Made) Ms. Park is a 78-year-old Korean American woman with a history of HTN. She presented to the ER with a headache and inability to recall recent information. Ms. Park states the pain is a throbbing, pounding sensation in the front of her head that has increased since yesterday. She states the pain is an uncomfortable pressure that hurts worse when lying flat. She tried ginseng and cold compresses at home with no relief. She reports difficulty concentrating with a 9/10 pain in the ER. Ms. Park reports nausea. Denies vomiting. Allergies (No Documentation Made) Latex (contact dermatitis) Past Medical History (No Documentation Made) HTN since age 54 3 pregnancies This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:14:34 GMT -05:00 https://www.coursehero.com/file/41314844/Focused-Exam-Cognition-Notes-Shadow-Healthpdf/ This study resource was shared via CourseHero.comStudent Response Model Documentation Past Surgical History (No Documentation Made) Cholecystectomy at 42 C-Section at 40 Medication History (No Documentation Made) Quinapril (Accupril) 10 mg daily for HTN, unable to recall last dose OTC use of ginseng in capsule form daily, dosage unknown Family History (No Documentation Made) Mother deceased at age 88, hx of HTN and DM Type II Father deceased at age 82, hx of HTN, hypercholesterolemia Maternal grandparents hx of coronary artery disease and DM Type II Paternal grandparents hx of obesity, CVA, HTN Siblings: Two brothers. Brother 80, hx of HTN, hypercholesterolemia, prostate cancer; brother, 81, hx of HTN Son, healthy, age 48 Daughter, healthy, age 46 Social History (No Documentation Made) Ms. Park is a retired nurse. She is a widow currently living with her daughter. She is sexually active and has a boyfriend. She denies past or present use of tobacco and illicit drugs. She states she drinks one glass of wine per week. This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:14:34 GMT -05:00 https://www.coursehero.com/file/41314844/Focused-Exam-Cognition-Notes-Shadow-Healthpdf/ This study resource was shared via CourseHero.comStudent Response Model Documentation Review of Relevant Systems (No Documentation Made) GENERAL: Negative for fever chills, night sweats, fatigue, weight change. RESPIRATORY: Negative for SOB, adventitious breath sounds. CARDIOVASCULAR: Negative for chest pain, palpitations, edema. GASTROINTESTINAL: Positive for nausea. Negative for vomiting and abdominal pain. Unable to recall last BM. NEUROLOGICAL: Positive for headache. Inability to recall recent information. Reports anxiety, mild insomnia, mood changes and difficulty with ADLs. Negative for fainting, numbness/tingling, dizziness, and falls. Functional Status and Geriatric Syndromes (No Documentation Made) Ms. Park lives with her daughter. Has her own room, and reports enough privacy. Reports no problems bathing, toileting, or dressing. Continent of bowels and bladder. No oral or dental problems, weight changes. Has some thin skin. Reports occasional confusion. Reports feeling less social lately, but denies that health or emotional problems are keeping her from being less social. In her gait test, Ms. Park had some observable sway. Her confusion and unsteadiness could put her at risk for a fall if her cognition worsens. This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:14:34 GMT -05:00 https://www.coursehero.com/file/41314844/Focused-Exam-Cognition-Notes-Shadow-Healthpdf/ This study resource was shared via CourseHero.comStudent Response Model Documentation Elder Abuse Assessment (No Documentation Made) Ms. Park is beginning to display some early signs of cognitive impairment, which will increase her risk of having her needs neglected. She stated that her daughter is already beginning to remind her to shower. She has stopped cooking for herself out of fear for her own safety. Eventually, she may need help with her ADLs and may need someone to check on her while her daughter is at work. She has a good relationship with her daughter and says she feels safe in her home. She feels good about how her money is being managed. I recommend in-home care checks to make sure that as her cognition declines she is able to get adequate care. This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:14:34 GMT -05:00 https://www.coursehero.com/file/41314844/Focused-Exam-Cognition-Notes-Shadow-Healthpdf/ This study resource was shared via CourseHero.com Powered by TCPDF (www.tcpdf.org [Show More]

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