Read the following case study and complete
Read the following case study and complete Part B. Case Study – Scenario Samuel Lee (D.O.B- 20/05/1956, MRN- 286572), was admitted to Royal Albert Hospital (North-side Road, Sydney), ward 6 B under the care of Doctor Campbell after falling at home on the 16/12/2015. He states he is allergic to Penicillin. He had a fractured neck of femur and multiple bruises. He usually walks with a frame but is very unsteady and needs supervision. He needs assistance with showering but can feed himself. He has access to Meals on wheels seven days a week. He is incontinent of urine but has a regular bowel habit (opens bowels once a day). It is noted that he has a small pressure area on his left hip. He is under the care of his GP to monitor his hypertension, cholesterol levels and diet-controlled Type 2 Diabetes mellitus. He denies any family history of cancers, heart disease or neurological disorders. He reports he sleeps well usually 10pm-6am. He does not smoke or drink alcohol. He is wearing spectacles. He uses a hearing aid (in situ). He has a full set of dentures (in situ). Samuel migrated from China 25 years ago and speaks and understands English well. His wife died 3 years ago and he has lived alone since her death. He has 2 children but both live inter-states. He has a sister Ming who is 78 and lives on her own. She has contacted the hospital and will visit her brother later. He has a caring neighbour called Joanne who checks on him regularly. Medications on admission: Amlodipine 10mg PO daily Atorvastatin 20mg PO daily Today: He was brought in by Ambulance. He has been given Paracetamol 100mgs IV in ED and started on oxygen therapy of 4L via nasal prongs (which is ongoing). . Part B Chart Mr Lee’s Vital Observation on the standard adult general observation chart provided below or you can use the form available at your workplace: Instructions to complete the form: Make sure all patient details are completed in all the pages of the form. Make sure that date and time is entered in the corresponding boxes for every entry/reading. Mark the observation using a dot at corresponding value in the box. If there are more than one reading, join them with a horizontal line except for B.P readings. Mark the Diastolic B.P readings with an arrowhead pointing down with its tip on the value in the box and systolic with an arrowhead pointing up with its tip on the value in the box and join both arrow heads with vertical dotted lines (Refer to- ‘Standard Adult Observation Chart Pg. 1 and 2’ under the topic “Collect and Process Workplace Information” in the Learning Resources). Make sure you initial every reading in the corresponding box. For pain readings, indicate with appropriate alphabets (M for movement and R for rest) against appropriate category (mild, moderate/ severe). Mr Lee’s hourly observation: Image transcription text FAMILY NAME NSW Health RIVEN NAME O MALE O FEMALE D.O.B M.O. STANDARD ADULT ADDRESS GENERAL O… Show more Image transcription text 0800hrs 130/80 8 — On Rest a. __} . 0900hrs __128/75 108 10 37 98% 8 V On Rest 1000hrs 135/85 95 12 36.5 96% 4.0 7 — … Show more
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