NURS 201 Focused Exam Cognition Notes Shadow Health

NURS 201 Focused Exam Cognition Notes Shadow Health

Nursing Admitting Note
Student Response Model Documentation
Chief Complaint (No Documentation Made) Patient came in with a pounding headache and
reports some recent memory loss.
Orientation (No Documentation Made) Alert and Oriented x 4
History of
Present Illness
(No Documentation Made) Ms. Park is a 78-year-old Korean American
woman with a history of HTN. She presented to
the ER with a headache and inability to recall
recent information. Ms. Park states the pain is a
throbbing, pounding sensation in the front of her
head that has increased since yesterday. She
states the pain is an uncomfortable pressure
that hurts worse when lying flat. She tried
ginseng and cold compresses at home with no
relief. She reports difficulty concentrating with a
9/10 pain in the ER. Ms. Park reports nausea.
Denies vomiting.
Allergies (No Documentation Made) Latex (contact dermatitis)
Past Medical
History
(No Documentation Made) HTN since age 54
3 pregnancies
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Past Surgical
History
(No Documentation Made) Cholecystectomy at 42
C-Section at 40
Medication
History
(No Documentation Made) Quinapril (Accupril) 10 mg daily for HTN, unable
to recall last dose
OTC use of ginseng in capsule form daily,
dosage unknown
Family History (No Documentation Made) Mother deceased at age 88, hx of HTN and DM
Type II
Father deceased at age 82, hx of HTN,
hypercholesterolemia
Maternal grandparents hx of coronary artery
disease and DM Type II
Paternal grandparents hx of obesity, CVA, HTN
Siblings: Two brothers. Brother 80, hx of HTN,
hypercholesterolemia, prostate cancer; brother,
81, hx of HTN
Son, healthy, age 48
Daughter, healthy, age 46
Social History (No Documentation Made) Ms. Park is a retired nurse. She is a widow
currently living with her daughter. She is
sexually active and has a boyfriend. She denies
past or present use of tobacco and illicit drugs.
She states she drinks one glass of wine per
week.
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Review of
Relevant
Systems
(No Documentation Made) GENERAL: Negative for fever chills, night
sweats, fatigue, weight change.
RESPIRATORY: Negative for SOB, adventitious
breath sounds.
CARDIOVASCULAR: Negative for chest pain,
palpitations, edema.
GASTROINTESTINAL: Positive for nausea.
Negative for vomiting and abdominal pain.
Unable to recall last BM.
NEUROLOGICAL: Positive for headache.
Inability to recall recent information. Reports
anxiety, mild insomnia, mood changes and
difficulty with ADLs. Negative for fainting,
numbness/tingling, dizziness, and falls.
Functional
Status and
Geriatric
Syndromes
(No Documentation Made) Ms. Park lives with her daughter. Has her own
room, and reports enough privacy. Reports no
problems bathing, toileting, or dressing.
Continent of bowels and bladder. No oral or
dental problems, weight changes. Has some
thin skin. Reports occasional confusion.
Reports feeling less social lately, but denies that
health or emotional problems are keeping her
from being less social. In her gait test, Ms. Park
had some observable sway. Her confusion and
unsteadiness could put her at risk for a fall if her
cognition worsens.
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Elder Abuse
Assessment
(No Documentation Made) Ms. Park is beginning to display some early
signs of cognitive impairment, which will
increase her risk of having her needs
neglected. She stated that her daughter is
already beginning to remind her to shower. She
has stopped cooking for herself out of fear for
her own safety. Eventually, she may need help
with her ADLs and may need someone to check
on her while her daughter is at work. She has a
good relationship with her daughter and says
she feels safe in her home. She feels good
about how her money is being managed. I
recommend in-home care checks to make sure
that as her cognition declines she is able to get
adequate care.
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