Use your own paper. Use narrative charting to thoroughly document…

Question Use your own paper. Use narrative charting to thoroughly document…   Use your own paper. Use narrative charting to thoroughly document care on each client. You can add in made-up assessments findings, but be sure to document everything we have provided that is relevant and use your nursing process. Due 10/4/21 midnight; scan and turn into Canvas. Completing the assignment gets you full credit. Please read our feedback on your completed assignment to learn from this.  You are caring for this client on the medical-surgical unit. A 68-year-old male admitted last night, presented to ER with SHOB and edema in bilateral lower extremities. The client has a history of CHF and HTN. VS today are: 148/85, 77, 22, 98.8, and 90%. The patient complains of mild SHOB but states it has improved since he presented to the ER. The client’s lungs have crackles bilaterally. He has 3+ pitting edema in bilateral feet. He has an IV in the left AC that is saline locked, it is CDI. He is on a fluid-restricted, heart-healthy diet. His wife is at the bedside. The client denies pain but complains of “feeling uncomfortable in my feet ” and mild anxiety about the extreme SHOB he experienced last night that brought him to the ER. He is concerned it will return. 2.  You received a report on your client for the day. Mr. P. is an 85-year-old man who has been a resident at the nursing home for the past 3 years and is S/P stroke prior to admission to the home. He is ambulatory and walks to the dining room for his meals. During the report, the night nurse states that he nearly fell during the night while making one of his frequent trips to the bathroom to void. Her assessment of the situation was that he was fine. When you go to his room to check on him, you note that his BP is normal for him and he is oriented X 4. He states that the “whole thing wouldn’t have happened if it weren’t for his lazy bum leg and the fact that he couldn’t find his glasses and is “blind” without them”. He also said that he was still kind of asleep when he got up and tends to be a little wobbly at times. He states, “It’s tough to be a weak old man. Old age isn’t for sissies!”  8 hours later: Before you go home, you note that the client is resting comfortably and has not fallen during your shift but he did complain about stumbling on the way to the bathroom. He used the call light most of the time when he needed to ambulate or switch from the bed to his walker. He was compliant about using non-skid footwear. The client’s glasses were always where he could find them.  3.  Chip Ireland is 35 years old and works as a businessman. He was admitted to the outpatient surgery center for a tonsillectomy. Postoperatively the nurse observes that he has difficulty swallowing and coughs up the water. He states, “My throat is too sore; it feels like it is swollen.” Upon examination, you note the presence of redness and edema in the operative area. The client also complains of nausea. You administer 4 mg IV Zofran as ordered. His VS are BP 137/69, HR 88, SpO2 96% on RA, RR 18, and temp 97.2. He rates his sore throat pain 6/10. 4.  Cassie Tilton is an 88-year-old woman transferred to your unit from a skilled nursing facility. Her history reveals that she had “flu-like” symptoms for the past five days with persistent vomiting and diarrhea. Her vital signs are B/P 108/56 while supine and 80/30 while sitting, the pulse is 130, respirations are 28 and her temperature is 101.4. Her mucous membranes are dry and her skin turgor non-elastic with tenting. She indicates that she feels weak, tired, and thirsty. She reports seeing a bug on the wall and asks you to remove it. You don’t see a bug anywhere. 5.  Your client is a 76-year-old male admitted to the hospital with pneumonia. He has been unable to eat and has lost 20 lbs. over the past 2 months. He had a CABG 3 years ago and follows up with his cardiologist yearly. He has HTN and takes a beta-blocker daily. He is put on telemetry monitoring. He also has NIDDM. He has limited mobility due to weakness from pneumonia, dyspnea, crackles bilaterally in upper lobes and diminished breath sounds in the lower lobes. He lives at home with his wife. Their children and grandchildren live nearby. VS: 101 temps, HR 121, BP 95/49. RR 26, SpO2 90% on RA. He is diaphoretic.  6. Michael Martinez is a 24-year-old Marine who was involved in an MVA while on leave. His face hit the dashboard, resulting in a fracture of the mandible. Surgery was done and involved an intermaxillary fixation (wiring). As a result of the surgery, he is limited in opening his mouth. He has been put on a liquid diet for now. He is concerned about losing too much weight and muscle to stay physically fit as a Marine.7. You are caring for a client in the labor ward. She presented with complaints of her “water breaking” at 12:30 pm with clear fluid. She arrived at your unit at 1:45 pm to be triaged. She is a 26 y/o F and this is her 3rd pregnancy. She had one miscarriage and one baby born at 32 weeks. She is currently 37 weeks and 2 days pregnant. Her labs are as follows: A+, rubella immune, GBS positive, HIV negative, Hep B and C negative, and GC/CT negative. The client changes into her gown and sits on the bed. You then apply the external fetal monitor at 1:57 pm. You verify the fetal heart rate in the 140’s by palpating the mother’s radial pulse at 82 while listening to the fetal heart rate monitor. While placing the monitors on the mother’s abdomen, you palpate fetal movement 3 times. You then check her vital signs which are: 128/74, HR 98, RR 18, Temp 37.4 C orally, and 97% SP02. At 2:02 pm, you ask the patient if you can check her cervix, to which she replies “yes”. At that time, you perform a sterile vaginal exam and find that she is 4/80/-1 and the baby feels cephalic. You noticed a moderate amount of clear fluid and a small amount of bloody show on your glove. The client tolerated the exam and you place her in semi-fowler’s position with a left tilt. While in the room with her, she has had contractions every 5 minutes that seem moderate when you feel her abdomen. You ask her to rate the pain on a scale from 0-10 and she rates them a 6/10. The client states she would like an epidural as soon as she can have one and would like IV pain medication as soon as she’s moved to her labor room. At 2:08 pm, you call Dr. Miller to let her know about the client and your assessment, and she responds with orders to admit the patient to labor and delivery, place an IV with LR @ 125mL/hr, admit labs including type and screen, continuous fetal monitoring, up ad lib, may receive 1mg stadol IV q3h PRN for pain greater than 4/10, and the client may receive an epidural when labs are resulted. She also orders a clear liquid diet and a return call once the epidural is placed and upon a cervical exam of 8cm.   Health Science Science Nursing HSNS 2118 Share QuestionEmailCopy link Comments (0)