Case
Robert Hall Focused Exam: Mobility (Part 2 of 2) shadow health
- Course
- Shadow health (SHADOWHEALT)
- Institution
- Arizona Medical Training Institute
Robert Hall Focused Exam: Mobility (Part 2 of 2) shadow health
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4/24/2020 Focused Exam: Mobility | In Progress Attempt | Shadow Healthhttps://westcoast.shadowhealth.com/assignment_attempts/6690339 1/4Focused Exam: Mobility (Part 2 of 2)
Medical Surgical Nursing: Promoting W ellness in the Older Adult - April 2020, nurs201-la_nurs201_202004spii_5 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
Illnesspain 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 inef fectiv 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. NKANursing Admitting...
SBARhttps://www.coursehero.com/file/60489202/Focused-Exam-Mobility-documentation-Shadow-Healthpdf/This study resource was
shared via CourseHero.com
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