NURS 201 Focused Exam Cognition SBAR Shadow Health

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SBAR Student Response Model Documentation 1. Situation Ms. Park is a 78-year-old Korean American woman admitted from ER today for HTN and change in mental status. 2. Background Ms. Park has a his... tory of controlled HTN until this episode. She was admitted through the ER today for a pounding headache and change in mental status for recent memory loss. The treatment plan includes an MRI to r/o CVA, pain control, BP control, and labs. The physician requested a 24-hour observation. A neuro consultation and psychiatric evaluation was also ordered. 3. Assessment Ms. Park is stable with a pain score of 4/10. Last given acetaminophen 650 mg for pain at 11:15. She was also given her daily Accupril 10 mg, PO and ordered hydrochlorothiazide 12.5 mg, PO for blood pressure at 11:15. Ms. Park was also given ondansetron 4 mg, IVP, for reported nausea at 11:30.. Current vitals: BP 160/90, HR 78, RR 14, 98% O2 sat., 37.0C. IV site is normal, no redness, swelling, or pain noted. Ms. Park's home medication for HTN is Accupril; she reports occasionally missing doses. I was able to confirm with Ms. Park's daughter that Ms. Park has missed doses for the past two days, and that Ms. Park's confusion has presented over the past two months. Ms. Park denies difficulty with ADLs, but reports confusion and recent decrease in social activity. I administered a brief cognitive assessment using word recall and a clock drawing test. Ms. Park was only able to recall 1 of 3 words and could not correctly complete the clock drawing test. She should receive additional cognitive testing. This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:15:07 GMT -05:00 https://www.coursehero.com/file/41314841/Focused-Exam-Cognition-SBAR-Shadow-Healthpdf/ This study resource was shared via CourseHero.comStudent Response Model Documentation 4. Recommendation Based on my assessment, I recommend the following: Review lab results. Administer Hydrochlorothiazide. DC IV fluids Complete an MMSE assessment to determine cognitive and functional status. Order consults. I recommend to contact the physician regarding his order for 0.5 mg alprazolam for anxiety. This medication is on the BEERS list of potentially inappropriate medications to avoid in elderly clients. The dose of alprazolam ordered is fine for an adult, but is double the recommended starting dose for a geriatric patient. This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:15:07 GMT -05:00 https://www.coursehero.com/file/41314841/Focused-Exam-Cognition-SBAR-Shadow-Healthpdf/ This study resource was shared via CourseHero.com Powered by TCPDF (www.tcpdf.org [Show More]

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