nurs 201 nurs201 focused exam infection notes shadow health graded a nurs 201 nurs201 focused exam infection notes shadow health graded a
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Focused Exam: Infection (Part 2 of 2)
Medical Surgical Nursing: Promoting Wellness in the Older Adult (Ontario) - April 2019, NURS 201
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Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor
insight into your learning process. This reflection activity will help you think more deeply about your performance in the assignment. Use your
documentation as you respond to the prompts at the bottom of the page.
Documentation Review
ED Nursing Note ED Nursing Note
SBAR Student Response Model Documentation
Chief Complaint (No Documentation Made) Patient reports frequent pain during urination,
abdominal pain, back pain, and periods of
confusion.
Orientation (No Documentation Made) Oriented to person. Only somewhat oriented to
situation; not oriented to place or time.
History of (No Documentation Made) Ms. Patricia Young is a 74-year-old White woman
Present Illness with a history of frequent UTIs and bladder
leakage. She is postmenopausal and presents
today to the ED with new onset confusion, fever,
generalized abdominal pain, CVA tenderness,
and burning with urination. She reports lethargy
and loss of appetite.
Allergies (No Documentation Made) NKA / NKDA
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