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NURS 201 Focused Exam Cognition SBAR Shadow Health

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NURS 201 Focused Exam Cognition SBAR Shadow Health

SBAR
Student Response Model Documentation
1. Situation Ms. Park is a 78-year-old Korean American
woman admitted from ER today for HTN and
change in mental status.
2. Background Ms. Park has a history of controlled HTN until
this episode. She was admitted through the ER
today for a pounding headache and change in
mental status for recent memory loss. The
treatment plan includes an MRI to r/o CVA, pain
control, BP control, and labs. The physician
requested a 24-hour observation. A neuro
consultation and psychiatric evaluation was
also ordered.
3. Assessment Ms. Park is stable with a pain score of 4/10.
Last given acetaminophen 650 mg for pain at
11:15. She was also given her daily Accupril 10
mg, PO and ordered hydrochlorothiazide 12.5
mg, PO for blood pressure at 11:15. Ms. Park
was also given ondansetron 4 mg, IVP, for
reported nausea at 11:30.. Current vitals: BP
160/90, HR 78, RR 14, 98% O2 sat., 37.0C. IV
site is normal, no redness, swelling, or pain
noted. 
Ms. Park's home medication for HTN is
Accupril; she reports occasionally missing
doses. I was able to confirm with Ms. Park's
daughter that Ms. Park has missed doses for
the past two days, and that Ms. Park's
confusion has presented over the past two
months. Ms. Park denies difficulty with ADLs,
but reports confusion and recent decrease in
social activity. I administered a brief cognitive
assessment using word recall and a clock
drawing test. Ms. Park was only able to recall 1
of 3 words and could not correctly complete the
clock drawing test. She should receive
additional cognitive testing.
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https://www.coursehero.com/file/41314841/Focused-Exam-Cognition-SBAR-Shadow-Healthpdf/
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shared via CourseHero.comStudent Response Model Documentation
4.
Recommendation
Based on my assessment, I recommend the
following: 
Review lab results.
Administer Hydrochlorothiazide.
DC IV fluids
Complete an MMSE assessment to determine
cognitive and functional status.
Order consults.
I recommend to contact the physician regarding
his order for 0.5 mg alprazolam for anxiety. This
medication is on the BEERS list of potentially
inappropriate medications to avoid in elderly
clients. 
The dose of alprazolam ordered is fine for an
adult, but is double the recommended starting
dose for a geriatric patient.
This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:15:07 GMT -05:00
https://www.coursehero.com/file/41314841/Focused-Exam-Cognition-SBAR-Shadow-Healthpdf/
This study resource was
shared via CourseHero.com
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