PROGROSS NOTE needs to be written in

PROGROSS NOTE needs to be written in SOAPIE format add an nursing recmmdtion to mr Sheldon Case study at the end FROM ADMISSON to all the tests that has been requid to be done for mr Sheldon Patient: Mr Sydney Sheldon. Age: 88 years of age.(DOB 11/06/1934) Address: 25 Elms Ave, Doncaster 3108. UR 123456 Admitting Doctor: Dr Want Admission Diagnosis: bronchitis & investigation of fall. Past History: Asthma. Hypertension. Osteo Arthritis. A series of falls over the past few weeks with increase in frequency in recent months. Lethargic, short of breath and fever. Medication: Antihypertensive (i daily). Panadol osteo (ii 6/24). Ventolin puffer (PRN) NOK: wife, ADL’s: Frequent Voiding. Reduced mobility due to pain associated with OA. Ambulate with assistance, reduced ability to perform ADL’s. Social: Mr Sheldon lives in his own home with his wife. Mr Sheldon is getting increasingly difficult to manage at home. Primary carer: Wife (who is 85 years old, is quite frail and displaying early signs of dementia). Previous admission vital signs (T 36.9. P 74. R 18, SaO2 97%, BP 126/86) Vital Signs On admission:- Temp 37.6 deg Pulse. 90, Resps 22, SaO2= 94% (on room air), BP 100/70. 1200 hrs T 37.4 P 86 R 20 SaO2 95% BP 98/64 1400 hrs T 37.5 P 84 R 22 SaO2 94% BP 96/64 1600 hrs T 37.3 P 82 R 20 SaO2 96% BP 96/68 When conducting a skin assessment on Mr Sheldon, you find a small graze in the left side of his forehead. You ask him how and when this happened. Patient states had a Fall at home this morning before admission. His wife said Mr Sheldon did not answer her when she found him on bathroom floor. Mr Sheldon said he did not hurt himself. He states he does not remember why he fell conducted a Neurological Assessment 1300 hrs GCS = 15 1400 hrs GCS = 14 patient disoriented. 1430 hrs GCS = 15 1500 hrs GCS = 15 1530 Hrs GCS= 14 patient disoriente Mr Sheldon is suffering from urine frequency. He forgets that you have left a urinal by his bedside and decides to get out of the chair to find the bathroom. In the rush to get himself to the bathroom, Mr Sheldon scrapes his left lower leg on the door of the bathroom. You are walking past his room just as this happens. You assist him to the toilet and then escort him back to bed for an assessment. On close inspection of Mr Sheldon’s left leg, it appears he may have an ulcer or skin abrasion on left lower leg. You escalate his care and report the incident to RN. You are asked to perform a neurovascular assessment & pain assessment on his left lower leg, whilst the RN writes up the hospital incident report.You re-educate Mr Sheldon on the use of the urinal (which is beside his bed) & remind him of how to use call bell for assistance, if he needs to get up from chair or out of bed. Mr Sheldon states he forgot it was there. You inform RN and agree that you will document in patient progress notes and NCP – that frequent reminders re using bottle to void and having call bell within reach. This will form part of nursing intervention to prevent further episodes of pressure risk, or potential falls, whilst Mr Sheldon is moving unaided around his hospital room Weight= 60 kgs. Height = 175cms Mr Sheldon is suffering from urine frequency. Mr Sheldon scraped his left lower leg on the door of the bathroom shortly after admission. He is still feeling light headed when he stands up. As a result of your nursing care measures since admission, (conducting lying and standing BP, each time you perform vital signs), Dr Want decides to withhold Mr Sheldon’s Antihypertensive medication. Dr Want takes time to seek you out and thank you for your nursing interventions, which assisted him in the diagnosis of postural hypotension in Mr Sheldon. You commenced a fluid balance chart on Mr Sheldon on his admission. This chart indicated that Mr Sheldon was voiding frequent, small amounts of urine into the urinal bottle. When emptying this bottle, you noticed his urine had a smelly odour to it, so you conducted a Full ward urine test. Mr Sheldon’s urine is showing Ketones and Protein in this full ward urine test. His urine test is also showing blood & leukocytes. You document these test results. Dr Want return to the ward next morning to review Mr Sheldon with the results of his tests. The MSU test results indicates an infection in Mr Sheridan urine. Dr Want informs you that the protein evident in urine (proteinuria), is due to blood in urine Dr Want informs you the ketones evident in Mr Sheldon’s urine is related to his current poor nutritional intake and request a Dietitian referral for Mr Sheldon Dr Want informs you the result of the MSU indicates a Urinary tract infection and orders oral antibiotics to treat this infection. ou document in patient progress notes and NCP – the current nursing care and changes to medication treatment for your patient. You continue to remind Mr Sheldon to using bottle to void and having call bell within reach. This information will form part of nursing intervention to prevent further episodes of pressure risk, potential falls, Fluid balance issues, resolution of urinary tract infection and continued assessment of Neurovascular status for Mr Sheldon. The RN arranges the Dietician to review Mr Sheldon for nutritional assessment and dietary plan (as per Dr Want’s referral) write a PROGROSS NOTE FOR THIS CASE STUDY

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."