Exam (elaborations)
NURS 201 Focused Exam Cognition SBAR Shadow Health
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NURS 201 Focused Exam Cognition SBAR Shadow Health
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SBARStudent Response Model Documentation
1. Situation Ms. Park is a 78-year-old Korean American
woman admitted from ER today for HTN and
change in mental status.
2. Background Ms. Park has a history of controlled HTN until
this episode. She was admitted through the ER
today for a pounding headache and change in
mental status for recent memory loss. The
treatment plan includes an MRI to r/o CVA, pain
control, BP control, and labs. The physician
requested a 24-hour observation. A neuro
consultation and psychiatric evaluation was
also ordered.
3. Assessment Ms. Park is stable with a pain score of 4/10.
m
Last given acetaminophen 650 mg for pain at
er as
11:15. She was also given her daily Accupril 10
co
mg, PO and ordered hydrochlorothiazide 12.5
eH w
mg, PO for blood pressure at 11:15. Ms. Park
o.
was also given ondansetron 4 mg, IVP, for
rs e reported nausea at 11:30.. Current vitals: BP
ou urc
160/90, HR 78, RR 14, 98% O2 sat., 37.0C. IV
site is normal, no redness, swelling, or pain
noted.
o
Ms. Park's home medication for HTN is
aC s
Accupril; she reports occasionally missing
vi y re
doses. I was able to confirm with Ms. Park's
daughter that Ms. Park has missed doses for
the past two days, and that Ms. Park's
confusion has presented over the past two
ed d
months. Ms. Park denies difficulty with ADLs,
ar stu
but reports confusion and recent decrease in
social activity. I administered a brief cognitive
assessment using word recall and a clock
drawing test. Ms. Park was only able to recall 1
is
of 3 words and could not correctly complete the
clock drawing test. She should receive
Th
additional cognitive testing.
sh
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