Millie Larsen, Part 2
Documentation Assignments
1. Document your physical assessment findings specific to Millie Larsen.
I performed a heat to toe assessment, and found nothing out of the ordinary. Her
skin looked intact and she was not sweating. Heart sounds were normal. I auscultated
bowel sounds in all four quadrants. Lung sounds were normal bilaterally, chest moving
normally, and breathing at 16 breaths per minute. Her IV site looked good, no swelling or
redness at site.
2. Document your assessment findings related to Millie Larsen’s functional status.
Millie Larsen seems to need some help getting in and out of the bathtub, but can
bathe herself independently. She in continent of her bowels and bladder while she does
wear protective underwear. She can independently dress herself and tie her shoes. Millie
also cooks for herself and does not need assistance with eating or opening cartons or
other things. She reports being able to get on and off the toilet, a chair, and a bed herself
as long as there is something to hold on to. Her daughter, Dina, is concerned for Millie
and does not think she should be left alone.
3. Document all patient teaching for Millie Larsen.
Patient teaching for Millie Larsen included her telling her how important is to
take her medication as ordered, what her medications are for, what side effects to look out
for, etc. I educated about safety; no throw rugs around the house, switch positions slowly,
wear sturdy shoes, have rooms well lit. I educated about her confusion and that it was due
to a UTI and what we are doing to treat it and how we can further prevent future
infections.