NURS 201 Focused Exam Cognition Notes Shadow Health

Nursing Admitting Note
Student Response Model Documentation



Chief Complaint (No Documentation Made) Patient came in with a pounding headache and
reports some recent memory loss.




Orientation (No Documentation Made) Alert and Oriented x 4




m
er as
History of (No Documentation Made) Ms. Park is a 78-year-old Korean American




co
Present Illness woman with a history of HTN. She presented to




eH w
the ER with a headache and inability to recall
recent information. Ms. Park states the pain is a




o.
rs e throbbing, pounding sensation in the front of her
head that has increased since yesterday. She
ou urc
states the pain is an uncomfortable pressure
that hurts worse when lying flat. She tried
ginseng and cold compresses at home with no
o

relief. She reports difficulty concentrating with a
aC s


9/10 pain in the ER. Ms. Park reports nausea.
vi y re


Denies vomiting.
ed d
ar stu




Allergies (No Documentation Made) Latex (contact dermatitis)
is
Th




Past Medical (No Documentation Made) HTN since age 54
sh




History 3 pregnancies




This study source was downloaded by 100000805705997 from CourseHero.com on 03-28-2021 02:14:34 GMT -05:00


https://www.coursehero.com/file/41314844/Focused-Exam-Cognition-Notes-Shadow-Healthpdf/