Question

Scenario 1: Selvi- [Urinary Tract Infection) Selvi is a morbidly obese 83 year old Sri•Lankan lady with a 15 year history of Chronic Renal Failure (CRF) and marked leg oedema. Selvi is on 2 litres of oxygen via nasal prongs due to breathing difficulties (uses home oxygen) and maintains a saturation of 92-95%. She has impaired mobility with a history of falls and uses a four wheeled frame for ambulation. She can understand English if it is spoken slowly and can respond using broken words. She uses reading glasses and her hearing is good. Selvi's condition recently deteriorated while she was at home and she was taken by her daughter to the Emergency department where she was diagnosed with Urinary Tract infection (UTI) and Urinary retention. Following initial treatment with IV antibiotics and subsequent assessment by an Aged care Assessment Team (ACAT) she has been recommended for high level care. On her arrival at the ward Selvi is anxious regarding her disease, Its prognosis, admission to the ward and subsequent transfer to an Aged Care Facility. You note she has an Intravenous Cannula insitu, R) Cubital Fossa and an Indwelling Urinary Catheter (IDC) (inserted in the Emergency Department). Selvi is vegetarian and prefers to have late dinner. The ED advise the following plan until further review by the Urology Unit: 4/24 vital signs Fluid Balance Chart (FBC) IV Antibiotics and analgesics (PRN only) Oxygen: 1-4 Litres/minute to maintain target Sa02> 92% 24 hour Urine Test & FBC FBE, U&E Examination findings: LOC: alert and oriented Height: 163cm Weight: 98kg Vital signs: T= 38.2°C, P=94/min R=28/min BP=149/86 mm of Hg Sa02=92% on 2 I of 02/min via nasal prongs Pain: 6 of 10 around the rib cage; aggravated with coughing.

Based on the above scenario, write the progress note for it.

Answer 1

The progress note for the above scenerio is as following

Date and Time	Focus/Title	Progress notes
XXX	*Oedema on leg *Pain *Breathing difficulty *Anxious/Anxiety	*83yr/old F with K/C/O CRF came with complaints of leg edema. Diagnosed as Urinary tract infection and urinary retention .Investigation like FBC ,FBE, U&E ,24 hour urine test are ordered .To administer antibiotics and monitor patient progress .Maintain intake output chart *Patient complains of pain in the rib cage and it aggravates during cough. She rates the pain at 6 of 10 in the pain scale. The patient is tachypneic with RR:28 .Adninister O2 at 2L via nasal prongs.The patient is having an oxygen saturation of 92% *Patient is tachypneic with RR of 28breath/min.Oxygen is administered via nasal prongs . *The patient expresses anxiety towards disease condition, prognosis admission and aged care facility .The patient has elevated blood pressure due to anxiety .The patient has to be provided reassurance ,psychological support, health education to cope up from anxiety