Mrs. Brown, age 85 years. She complained of falling into her chair at home, dribbling when trying to get to the bathroom, being tired, and not being hungry for 1 week. The primary care provider evaluated a urinalysis and complete blood count (CBC) with differential and recommended admission to rule out sepsis and urinary tract infection. Mrs. Brown is a widow of 3 years, was married for 62 years, has three adult children, and lives in her own home with an unmarried son. She has a history of two incidents of CHF 4 years ago, a hysterectomy 22 years ago, an left knee replacement 15 years ago, and situational depression when her husband passed away. VS: BP: 140/88 mmHg, P: 90 beats/minute, RR: 22 breaths/minute, T: 35.7°C.
What are the:
1. Assessment: This section contains the interpretation of what was noted in the Subjective and Objective sections, such as a nursing diagnosis in a nursing progress note or the medical diagnosis in a progress note written by a health care provider.
2. Plan: This section outlines the plan of care based on the Assessment section, including goals and planned interventions.
3. Interventions: This section describes the actions implemented.
4. Evaluation: This section describes the patient response to interventions and if the planned outcomes were met.