Mrs. Smith The nurse is reviewing the medical record of Gladys Smith, a new patient. Patient Information Nurses' Notes P

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Mrs Smith The Nurse Is Reviewing The Medical Record Of Gladys Smith A New Patient Patient Information Nurses Notes P 1 (33.93 KiB) Viewed 53 times

Mrs Smith The Nurse Is Reviewing The Medical Record Of Gladys Smith A New Patient Patient Information Nurses Notes P 2 (40.29 KiB) Viewed 53 times

Mrs. Smith The nurse is reviewing the medical record of Gladys Smith, a new patient. Patient Information Nurses' Notes Patient Name: Gladys Smith Age: 58 Gender: Female Question 2/2 Use the drop-down menus to complete the nursing diagnosis for Mrs. Smith, related to evidenced by fatigue, and thick oral secretions. and perceived weakness as
Suomi Patient Information Nurses' Notes S: Situation Ms. Smith lives alone. Up until four weeks ago she was healthy and not taking any medications. Although she had been tiring easily, she attributed that to a project at work that was behind schedule. B: Background • No known allergies • Recent medical history: cerebral vascular accident (CVA, stroke) 4 weeks prior to admission • Non-ambulatory • Being admitted rehabilitation facility from hospital A: Assessment Subjective Data • "Tam so weak I cannot feed myself or brush my teeth." • "All I want to do is sleep." . "The doctor says I may never live by myself again." • "My clothes are too big since I've lost so much weight." Objective Data • Weight 100 lb (down from 115 lb when admitted to hospital) Limited range of motion bilateral shoulders • Non-ambulatory, can transfer from chair to bed using walker • Thick oral secretions • Sores in mouth • Halitosis Speaks slowly and quietly