University:
Thomas Jefferson University
Course:
NUR300 | Health Promotions 2
Academic year:

2023
Views:

116

Pages:

1
Author:

Ethan Mercado

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.

Millie Larsen Part 2 Documentation

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