solved

Question
Answered step-by-step
Asked by UltraChimpanzee2224

(WHAT WILL BE SOAPE NOTE FOR THIS SENARIO )?

You arrive for your shift in the long-term care home at 0645. You receive report from the night
staff on all of your assigned clients and are ready to start your rounds at 0710. Based off the
report you prioritize your assessments and go to see Client 5 first. You walk down to the client’s
room and find your normally independent client sitting on the floor at the end of the bed. When
you ask them what happened, they reply “I was trying to go to the bathroom, and I got really
light headed and weak.” You inquire if they hit their head or if anything hurts and they tell you
they did not hit their head and state “I’m fine, the only thing hurt is my pride”. You assist the
client off the floor to sit on the edge of the bed and then assess their vital signs. The vitals signs
were taken at 0715 and are as follows:
BP: 128/80 on the left arm, HR: 92 regular, Temp: 36 C oral, Resps: 20, SpO2: 96% on R/A,
Blood Sugar: 6.4mmol/L
You then assist your client to the washroom and ensure they safely get to the dining room for
breakfast. You inform the charge nurse of the incident. The charge nurse tells you that the doctor
will be doing rounds later this morning and will be notified of these events.COMP 582 ELECTRONIC DOCUMENTATION TEST: PCC
After breakfast you walk with client 5 back to their room and see them safely to their chair. It is
now 0815 and when you inquire if they are experiencing any pain, they reply with “no, not really”.
You ask them to rate their pain on a scale of 0-10 and they state it is “about a 1”. At this time the
physician arrives and comes in to assess the client. The physician gives you a verbal order to
complete orthostatic blood pressures.
The client agrees to this assessment and you assist them into the bed where they will lay supine
for 3-5mins. You assess the first blood pressure at 0830 and find it to be 136/88 on the left arm.
You assist the client to a sitting position, keeping the blood pressure cuff on the left arm, and
wait 3 minutes before rechecking the blood pressure. At 0833 the resident’s blood pressure is
122/80. Lastly you help the client to a standing position and wait another 3 minutes. The
resident’s blood pressure while standing is 101/68 on the left arm at 0836. The client also
complains of feeling slightly dizzy while standing. You help them to safely sit back down on the
bed and instruct them not to get up without assistance. You ensure the call bell is in reach and
inform both the charge nurse and the physician of the results.

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."