Millie Larsen part 1 documentation PDF

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Millie Larsen, Part 1 Documentation Assignments 1. Document your physical assessment findings specific to Millie Larsen. Patient’s lung sounds are normal bilaterally along with normal heart sounds. I heard bowel sounds in all four quadrants. She has normal skin turgor and is not sweating. Her IV access looks good, no swelling or pain at site. 2. Document your findings from the Confusion Assessment Method (CAM). Millie Larsen’s daughter, Dina, reported that her mother’s onset of confusion is sudden. Dina said her mother has had an inability to keep a conversation without getting distracted or starting to ramble. Millie seems confused and is disoriented to time and situation. Her level of consciousness has not changed from baseline; patient is alert. Patient tested positive for the CAM. 3. Referring to your feedback log, document the nursing interventions you performed. The nursing interventions I performed included reorienting and educating the patient and her daughter as much as possible. I performed a head to toe assessment, a urinalysis, a CAM, and a MORSE falls risk assessment. I administered medications as ordered. I informed patient and family of UTI’s and how they can later be prevented. I educated about safety and provided emotional support for patient and family. 4. Document your report to the physician using the situation-background-assessmentrecommendation (SBAR) format. Millie Larsen, 84-year-old female. Her daughter, Dina, brought her in because she was very confused and could not hold a conversation without getting distracted. Her urinalysis and CBC confirm a urinary tract infection. She is also hypertensive; we believe she has not been taking her medication at home. She is dehydrated, but she has fluids running. I administered 400 mg of Ciprofloxacin IV, 25 mg Captopril PO, and 100 mg Metoprolol PO. I also gave 650 mg Acetaminophen PO, because she was complaining of a headache. Her CAM came back positive and she is a falls risk. her head to toe assessment shows no problems, she says she walks without assistance but I instructed her to stay in bed as much as possible since she is confused.

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