Judy Jones Report Writing, Charter College Nursing Programme, Pathophysiology, Medical Diagnosis & Musculoskeletal - Nursing Assignment Help

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Hand Off Report

Judy Jones is an 85-year-old patient of Dr. Annette Parks admitted 8 days ago with a diagnosis of community-acquired pneumonia. We treated her with IV antibiotics and respiratory treatments, and it has resolved. Ms. Jones has a medical history of cervical spondylosis and hyperlipidemia that is controlled by diet. She has minor neurocognitive disorder due to Alzheimer’s disease, and during this hospitalization, she developed delirium that was manifested by seeing children underneath her hospital bed, agitation, and wandering the halls. She was given lorazepam 1 mg, which seemed to help initially, but she became more agitated and delirious after a second dose of 2 mg.
Her last set of vital signs were temperature 98.6 F, HR 76, RR 18, BP 128/64, pulse oximetry 96% on room air. Ms. Jones is alert and oriented to self, but still needs periodic orientation to time and place. She is forgetful, but her confusion has been diminishing each day. The last three nights she has not been sleeping well.

Ms. Jones occasionally has a productive cough of white sputum. Her lungs are clear Occasionally you will hear scattered rhonchi that clear with coughing and deep breathing. She needs to be reminded to use her incentive spirometer and how to use it.

Ms. Jones is on a regular diet and has a good appetite. Her abdomen is soft with positive bowel sounds; her last bowel movement was this morning. She is ambulating to the bathroom with a steady gait and urinating without difficulty. Her skin is clean, dry, and intact with no areas of breakdown. Tomorrow Ms. Jones is scheduled to be transferred to a rehabilitation center for a short time before returning home. Her daughter and primary caretaker Karen is at the bedside and is concerned about her mother’s discharge, her mental condition, and how she will manage her at home.

1-Primary Medical Diagnosis: 
Etiology specific to the patient (How would you explain the disease process to your patient): Patient Presentation (Patient symptoms from your assessment):

2-Secondary Medical Diagnosis: 
Etiology specific to the patient (How would you explain the disease process to your patient): Patient Presentation (Patient symptoms from your assessment):

Significance of findings related to medical diagnosis:

1-Respiratory
2-Integumentary
3-Gastrointestinal
4-Musculoskeletal
5-Genitourinary
6-Immunity
7-Reproductive
8-Lines/Drains/Tubes
9-Integumentary
10-Psychosocial/Spiritual Well-Being
11-Patient Problems
12-Laboratory/Diagnostic Tests
13-Nursing Diagnostic Statement
14-Nursing Interventions and Rationale.
 

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