Mrs. Brown, age 85 years. She complained of falling into her chair at home, dribbling when trying to get

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.

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