TURING THIS INTO AN SOAPIE – subjective,
TURING THIS INTO AN SOAPIE – subjective, objective, assessment, plan, intervention, and evaluation. for met progress note PROGROSS NOTES Mr Sydney Sheldon is an 88-year-old male who presented to the hospital with a diagnosis of bronchitis and investigation of fall. His past medical history included asthma, hypertension, and osteoarthritis. He had recently experienced a series of falls with increasing frequency in the past few weeks. Upon presentation, he was lethargic, short of breath, and had a fever. His vital signs were a temperature of 37.6°C, pulse of 90, respiration of 22, SaO2 of 94%, and BP of 100/70. A neurological assessment revealed a GCS of 15 on admission. However, at 1400 hrs the GCS dropped to 14 and the patient was disorientated. At this time, Dr Want was notified and the GCS returned to 15 by 1500 hrs. In addition, a skin assessment revealed a small graze on the left side of his forehead. Upon questioning, Mr Sheldon stated he had a fall in his bathroom that morning before admission. His wife had found him on the bathroom floor and he did not remember why he fell. Mr Sheldon is suffering from urine frequency, which caused him to get up from his chair to find the bathroom. In the rush, he scraped his left lower leg on the door of the bathroom. The nurse on duty found him and assisted him to the toilet. Upon inspection, it was found that he had an ulcer or skin abrasion on his left lower leg. The incident was reported to the RN and a neurovascular assessment and pain assessment were conducted. The patient was re-educated on the use of the urinal by his bedside and the use of the call bell for assistance. Dr Want conducted a full ward urine test and the results revealed ketones, protein, blood and leukocytes in the urine. Based on these results, Dr Want diagnosed a urinary tract infection and ordered oral antibiotics to treat the infection. In addition, a referral was made to a Dietician for nutritional assessment and dietary plan. As Mr Sheldon was suffering from postural hypotension, Dr Want withheld his antihypertensive medication. The nursing care plan included frequent reminders to Mr Sheldon to use the bottle to void and keep the call bell close by to prevent further episodes of pressure risk, potential falls and fluid balance issues. The patient was also monitored for resolution of the urinary tract infection and continued assessment of the neurovascular status. Dr Want thanked the nursing staff for their interventions, which assisted in the diagnosis of postural hypotension. Overall, Mr Sheldon remains in stable condition. Vital signs remain stable and he is currently being managed with antibiotics for the urinary tract infection. He is being monitored for resolution of the urinary tract infection and continued assessment of the neurovascular status. Nursing interventions of frequent reminders to Mr Sheldon to use the bottle to void and keep the call bell close by to prevent further episodes of pressure risk, potential falls and fluid balance issues, are ongoing.
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