Write soap note and narrative charting

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Reference no: EM133912699

Question

An RPN on the day shift on the surgical unit. She is caring for Mrs. Lombardi, an 89-year-old woman admitted to the surgical team at 1630hrs from the emergency room. Mrs. Lombardi was brought to the Emergency department from her long-term care facility after falling from her bed. She is a no-code status (not to be renewed if she should have a cardiac or respiratory arrest) and has no known allergies. She has a history of dementia. Mrs. Lombardi has been admitted for possible surgery for a fractured left hip. She was given morphine IV at 1800hrs and is not complaining of pain. Her skin is intact, and she is receiving Normal Saline in her right forearm. Vital signs are BP 130/70, P-70, Temp. 36, Resp. The staff has notified 20, Oxygen saturation 98% on 2/Litres Nasal Prong and family that she is in the hospital. Surgery is a possibility for the morning, but the surgeon has not confirmed this yet. The night staff will have to follow up on this and inform the family once a confirmed decision.

Write SOAP Note and Narrative Charting.

Reference no: EM133912699

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