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– 73-year-old female – LMP at age

– 73-year-old female – LMP at age 54 – CC: “I wake up 4-5 times a night to go to the bathroom. Sometimes I leak urine as I am going to the bathroom during the daytime. Is there anything you can do or I can do?” Subjective Data – What other information is needed from her HPI? – What other info do you need about her medical history? – She’s 63 years old, and she most likely has a medical history. Develop it. -Please document in paragraph format. Objective Data – Include vital signs – Include point of care testing (POCT) (if appropriate) – Include an appropriate exam Assessment – Include ICD 10 code – Include DDX Plan – Consider what is the first step of intervention/management for her – Include what other possible management can be done after the initial step – What would be another possible management but she MAY NOT BE AN IDEAL CANDIDATE FOR – Include medication (if appropriate) – Include education, teaching, follow-up, and referral (if appropriate) SCIENCE HEALTH SCIENCE NURSING NURS 6053

 
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