Patie Report from paramedics: The patient is a 73-year-old w
Patie Report from paramedics: The patient is a 73-year-old woman,… PatieReport from paramedics: The patient is a 73-year-old woman, Lucy Grey. She called 911 after having a dizzy spell and a near fall in her home. When we arrived, she was sitting on her couch in her living room. Her blood pressure is 160/88, heart rate is 102, respirations are 20, and her oxygen saturation is 97%. She is on 2 liters of oxygen per nasal cannula. She was alert, coherent, and apologetic for calling us. Denies taking any medications today, states she had tea and oatmeal for breakfast. No complaints of pain, mobilizes without assistance, a little slow due to” stiff knees.” There is a scrape on her arm; we just taped a gauze pad on it. We have a saline lock in her right forearm. She told us that her partner, Julia, died from lung cancer three months ago and that she has been scared of being alone after the loss of her partner. Julia’s son, Neil, has been called, and he should be here any minute.Patient DetailsPatient Data: Female – age 73 years. Weight: 50 kg (110 lbs). Height: 162 cm (64 in).Allergies: No knownPast Medical History: Osteoarthritis, right knee.History of Present Illness: History of falls, once a month since the death of her partner. Had comprehensive neurological work-up with no physiological abnormalities noted. Social History: Single, lives alone, partner Julia Morales died three months ago. Retired teacher.Primary Medical Diagnosis: Fall at home.Surgeries/Procedures & Dates: Right knee replacement at age 65.Provider’s Orders Not received yet Conditions OsteoarthritisHypertensionAnorexiaDizziness PROCEDURES and DIAGNOSTIC TESTS (oxygen, O2 Sat level, radiography, etc.). Please complete the table for procedures listed in the preparation for vSim. Add rows as needed. TEST/DATE What is the purpose of this test (text reference)Why ordered for this patient (related to primary dx?) Plan of care implications?Nursing actions that require assess or follow up (npo, diet changes, med change)Blood Pressure Assessment Fall prevention TEST Normal RangePurposeWhy ordered for this health problemNursing actions that require assessment or follow up (npo, diet changes, med change)Potassium Level, Serum Health Science Science Nursing NRSE 2030
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