4/10/202
0 Focused Exam: Documentaiton of nursing admit note Pain-Only two attempts
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Focused Exam: Pain-Only two attempts determine student score.
Further attempts not be counted toward grade. Results | Completed
Caring in Adult/Elderly Health I: Practice - March 2020, NUR 334
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Transcri Flowsheets Nursing Admitting Note
pt
Subjective Data
Collection
Objective Data
Collection Education Nursing Admitting Note
& Empathy QSEN Student Documentation Model Documentation
Competencies
Documentation
Mr. Carter woke up with severe arthritic pain in his hips
SBAR Chief Complaint and knee this morning. Upon standing from bed, his
joints gave out and he collapsed in his bedroom. He hit
Osteoarthritis and fell this
Reflections his back on the bed frame as he He verbalizes that he is
morning.
worried about getting around on his own well as about
his osteoarthritis worsening over time.
Orientation
A&O x 4
Patient is AAOX3
Mr. Carter is a 68-year-old African American male with a
history osteoarthritis, CKD, HTN, and Afib who presents
to the ER today complaints of worsening pain and
stiffness of his hips and knees weakness of his lower
back with a recent fall. He says the pain a stiffness was
the worst it has ever been and resulted in a fall out bed.
History of Present Illness He hit his back on the bed frame and now has redness
and tenderness to his lower back.
Has had Osteoarthritis since the age
of 66. He describes the pain as aching and dull and worsens
with the c weather. He states that rest usually relieves
the pain, moist heat helps his hips and elastic supports
on the knees is helpful. Napro helps with the chronic
pain. He states that he presented to the emergency
department today due to worsening pain. Upon arriv the
https://app.shadowhealth.com/assignment_attempts/6568373 1/3
https://www.coursehero.com/file/61053211/Documentaiton-of-nursing-admit-notepdf/
, 4/10/202
0 ER,
Focused Exam: Documentaiton of nursing admit note Pain-Only two attempts
he reports pain level of his knees, hips
and lower back a 9/10. He reports
increasing fatigue for the last 3 months. He den any
nausea, vomiting, and weight loss.
This study source was downloaded by 100000815611969 from CourseHero.com on 01-04-2023 01:20:53 GMT -06:00
https://app.shadowhealth.com/assignment_attempts/6568373 2/3
https://www.coursehero.com/file/61053211/Documentaiton-of-nursing-admit-notepdf/
0 Focused Exam: Documentaiton of nursing admit note Pain-Only two attempts
Our Technical Support team will be unavailable Easter Sunday, 4/12/2020. We will resume normal business on Monday, 4/13/2020, at 9 AM EDT. Your
success is extremely impo so be assured that we will respond to your emails and calls ASAP on Monday. r
Focused Exam: Pain-Only two attempts determine student score.
Further attempts not be counted toward grade. Results | Completed
Caring in Adult/Elderly Health I: Practice - March 2020, NUR 334
Return to Assignment (/assignments/317492/)
Your
Turn In (/assignment_attempts/6568373/choo
Results
Reopen (/assignment_attempts/6568373/reopen
Lab Pass (/assignment_attempts/6568373/lab_pass.p
Overvie
Documentation / Electronic Health Record
w
Transcri Flowsheets Nursing Admitting Note
pt
Subjective Data
Collection
Objective Data
Collection Education Nursing Admitting Note
& Empathy QSEN Student Documentation Model Documentation
Competencies
Documentation
Mr. Carter woke up with severe arthritic pain in his hips
SBAR Chief Complaint and knee this morning. Upon standing from bed, his
joints gave out and he collapsed in his bedroom. He hit
Osteoarthritis and fell this
Reflections his back on the bed frame as he He verbalizes that he is
morning.
worried about getting around on his own well as about
his osteoarthritis worsening over time.
Orientation
A&O x 4
Patient is AAOX3
Mr. Carter is a 68-year-old African American male with a
history osteoarthritis, CKD, HTN, and Afib who presents
to the ER today complaints of worsening pain and
stiffness of his hips and knees weakness of his lower
back with a recent fall. He says the pain a stiffness was
the worst it has ever been and resulted in a fall out bed.
History of Present Illness He hit his back on the bed frame and now has redness
and tenderness to his lower back.
Has had Osteoarthritis since the age
of 66. He describes the pain as aching and dull and worsens
with the c weather. He states that rest usually relieves
the pain, moist heat helps his hips and elastic supports
on the knees is helpful. Napro helps with the chronic
pain. He states that he presented to the emergency
department today due to worsening pain. Upon arriv the
https://app.shadowhealth.com/assignment_attempts/6568373 1/3
https://www.coursehero.com/file/61053211/Documentaiton-of-nursing-admit-notepdf/
, 4/10/202
0 ER,
Focused Exam: Documentaiton of nursing admit note Pain-Only two attempts
he reports pain level of his knees, hips
and lower back a 9/10. He reports
increasing fatigue for the last 3 months. He den any
nausea, vomiting, and weight loss.
This study source was downloaded by 100000815611969 from CourseHero.com on 01-04-2023 01:20:53 GMT -06:00
https://app.shadowhealth.com/assignment_attempts/6568373 2/3
https://www.coursehero.com/file/61053211/Documentaiton-of-nursing-admit-notepdf/
