Question Answered step-by-step I need to know if I missed anything, and what other information… I need to know if I missed anything, and what other information would you teach this patient about?I – Good afternoon, this is Nurse C calling from Southshore Care facility and Rehab calling regarding your 67 yr old patient by the name of john Doe.S- He recently had a fall with no injury to head, However, he is c/o of pain in left arm with minimal bruising, limited ROM and had been showing signs of confusion and delirium.B- John has just recently moved in about a month ago. He was living alone before he moved to the community. He has a history of asthma, allergies, HTN, and early onset dementia.He did not come to the community with any orders or meds for asthma management. A – His vitals are as followed, B/P 139/76 HR 70 T- 100.0 spoO2 94%RA. Post fall assessment showed limited ROM to left arm with bruising, no swelling, no injury to head. I did notice wheezing upon auscultation of patient’s lungs but he does not look to be in respiratory distress. He stated his asthma is an issue in the warmer months. Assisted him into his recliner and cleared a path in his room to walk as he still had things in boxes from the move. He was not using his walker at the time of fall. I did observe him guarding his left arm and grimacing. Prn Tylenol given for pain and temp management, which according to Mr. Doe, the pain was a 6 out of 10 but he refused to go to the ED.R – I would like an order for an X-ray the left the r/o possible fracture, UA w/ CS for possible UTI, and order for a rescue inhaler or neb treatment. Also, a CBC, BMP because I noticed Mr. Doe had no updated labs upon his move-in, and order for PT/OT is suggested. Please advise any addition action you like taken for the acute care of this patient. Health Science Science Nursing NURSING 254 Share QuestionEmailCopy link Comments (0)
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