Question

20 Fundamental Skills Nursing Report Mrs. Paransoky is an 83-year-old patient of Dr. Benoffsky. She was admitted last night with the diagnosis of syncope and change in mental status. She has a history of HTN, CAD, and CHF. She lives alone; her daughter found her at home on the floor, a little confused and unsure as to what had happened. There was no apparent injury. She called 911. The patient is Russian and speaks very little English. Her daughter said she would be in early this morning Neurological: She slept most of the night, she is awake, alert, oriented to person, but confused to time and place, but reorients easily. PERRLA 3 mm, GCS 14. Cardiac: Telemetry, monitor NSR, BP 140/80. Resp: Lungs clear anterior, posterior decreased with few bibasilar crackles, pulse ox 93% on 2 L via nasal cannula. MS: Moves all extremities, but generalized weakness. VS: 9 4 hr with neuro check, BP supine, sitting, and standing Accu checks with coverage ae and hs. She has an IV #22 left hand 5 % dextrose/0.45 % NSS 12 h She is on bed rest, no added salt diet. She is scheduled for lah work and carotid us.

Answer 1

Relevant data from report	Relevant data from other sources	Data missing	Sources of missing data	Data requiring follow up
Past medical history	Mental status examination	Vital signs	complete physical assessment findings	History collection
Present complainta	Radiological findings	cardiac markers level	Lab tests	Head to foot examination
Onset of symptoms	Patient care sheet	Radiological reports	Radiological reports	lab and radiologic report
Physical assessment findings	Doctors progress note	previous medication therapy	Incomplete History collection	Review reports