Focused Exam: Mobility | In Progress Attempt | Shadow Health | Medical Surgical Nursing: Promoting Wellness in the Older Adult

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Focused Exam: Mobility | In Progress Attempt | Shadow Health https://westcoast.shadowhealth.com/assignment_attempts/6690339 1/4 Focused Exam: Mobility (Part 2 of 2) Medical Surgical Nursing: Promot... ing Wellness in the Older Adult 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 Nursing Admitting Note Student Response Model Documentation Chief Complaint pain in leg for few days and calf is swollen red. Mr. Hall reports severe cramping pain and swelling in his lower leg, as well as a fall due to dizziness upon standing Orientation alert and oriented x4. A&O x 4 History of Present Illness pain two days ago in abdomen. pain in lower left calf. fell when getting out car and was dizzy. Mr. Hall is an 80-year-old White man with a history of HTN BPH with urinary incontinence, and arthritis who presente the ER with complaints of left lower leg pain x 2 days and dizziness. He describes the pain as being localized to the lower leg. He says the pain was increasingly severe yesterday and noticed that his calf was swollen. He describes the pain a sharp, nagging and constant. He also states that this pain different from the usual arthritis pain he gets in his hips an knees and that nothing makes the pain better or worse. H tried taking Advil for the pain at home, but it was ineffectiv Upon arrival to the ER, he reports pain level 10/10 and describes it as a cramp like pain that won't ease up. Patie reports feeling dizzy for about 2 weeks, since he has had prescription refilled. Has fallen in the past prior to the fall yesterday. However, he did not have any major injuries as result of these falls. Allergies no allergies. NKA Nursing Admitting... SBAR 4/24/2020 Focused Exam: Mobility | In Progress Attempt | Shadow Health https://westcoast.shadowhealth.com/assignment_attempts/6690339 2/4 Student Response Model Documentation Past Medical History hypertension, osteoarthritis, and enlarged prostate. HTN, diagnosed at age 57 Arthritis, diagnosed at age 57 Prostate enlargement with minimal urinary incontinence, diagnosed at age 69 Past Surgical History adbominal hernia at 58 years old. Mr. Hall reports that he had one previous surgery for abdominal hernia at age 58. Medication History Metoprolol 50mg tablet 1/2 tablet by mouth daily fill date: 04/20 expiration: 06/20 Metoprolol 25 mg, 1 tab daily for high blood pressure. Las dose this morning Finasteride (Proscar) 5 mg, 1 tab P.O. once a day last do day ago Benadryl, dosage unknown, 1 tab PRN as a sleep aid, las dose earlier this week [Show More]

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