Summary NSG 6020 - WEEK_7_8_9.

Running head: NSG 6020 WEEK 9 SOAP RH 1 NSG 6020 Week 9 SOAP RH Constance Mahin South University Advanced Assessment NSG 6020 Dr. T. Berry September 10, 2018 This study source was downloaded by from CourseH on :48:41 GMT -05:00 This study resource was shared via CourseH NSG 6020 WEEK 9 SOAP RH 2 NSG 6020 Week 9 SOAP RH Name: RH Age: 68 Gender: Female Wgt: 151 (-3) BMI 26.4 Code Status: FC Pulse: 68 BP: 127/76 O2: 96% RA RR: 18 Temp: Afebrile Allergies: PCN and Latex CC: Wellness Visit (Comprehensive) HPI: MS with contractions is her predominant diagnosis (Primary) PMHx: diabetes, MS w/contractions, neurogenic bladder, GERD, CKD Stg II, HLD, Constipation, Recurrent UTI, Anxiety and Depression (MDD was mild at mother’s death) SoHx: Patient is a residence of this facility and has been since 2005. Until recently, she shared a room with her mother and was her caregiver prior to reaching the need for long term care herself. She and her mother shared a room in the facility until July 2018 when her mother passed. MDD flared at that time and PRN Ativan was given for a short time with success. She no longer requires and has refused Cymbalta. Medications: Baclofen 20 mg q day; K+ 20 mEq daily; Belsomra 10 mg HOS, atorvastatin 20 mg HOS; Claritin 10 mg HOS; flagyl 500 mg bid; hydrocodone 5/325; Subjective/ROS: General: denies; Resp: denies; Cardio: denies; GI: denies; GU denies; MSK: denies; Neuro