Diagnosis: Dehydration and Urinary Tract Infection (UTI)
Code Status: Full code
Allergies: No known allergies
Medical History
Hypertension
Glaucoma
Osteoporosis
Arthritis
Elevated Cholesterol
Stress Incontinence
Medication Compliance: Uncertainty regarding recent medication intake; daughter unable to verify if medications were taken from medication box.
Admission Details
Admitting Unit: Medical-Surgical (med surg)
Initial Source of Admission: Emergency Department (ED)
Reason for ED Visit: Patient was confused and not acting normally during daughter's visit.
Time of Admission: Patient admitted to med surg after spending the night in the ER before a bed became available about one hour prior to the current observation.
Background Summary
Millie's daughter, Taylor, visited the patient yesterday evening and reported confusion.
Patient was brought to the ED where she was evaluated and subsequently admitted.
Vital Signs at 0600
Heart Rate: 86 bpm
Blood Pressure: 176/98 mmHg
Respiratory Rate: 16 breaths per minute
SpO2 (Oxygen Saturation): 97% on room air
Temperature: 98°F
Pain Level: 0 (none reported)
Nursing Actions and Recommendations
Initial Physical Assessment: To be performed by the day shift nurse.
CAM (Confusion Assessment Method) Evaluation: Completion of CAM assessment recommended for evaluating cognitive function.
SPICES Evaluation: To be conducted, focusing on common geriatric syndromes: Sleep disorders, Problems with Eating, Incontinence, Confusion, Evidence of Falls, and Skin Breakdown.
Physician Information
Doctor in Charge: Dr. Garcia
Follow-Up: Dr. Garcia will see the patient later in the morning.
Family Communication
Taylor (patient's daughter) has left to change clothes and will return within one hour but is available by phone if needed.