Patient Assessment Paper

Today I have the pleasure of working with a client named Mrs. Reyes, a 75-year-old female of Hispanic descent. She is a non-insulin diabetic, who lives alone, but has regular visits from her children and grandchildren. Mrs. Reyes has been admitted as a result of an acute change in mental status, and secondary with a diagnoses of a urinary tract infection and dehydration. Mrs. Reyes has a history of many falls at home previous to being admitted therefore she is a fall risk. I am nervous about how the day will go as this is the first time I will be working with Mrs. Reyes, and from report it appears that she did not have the most pleasant night.
Upon entering Mrs. Reyes’s room, which had no precaution signs, therefore no PPE was required to be worn. “Good Morning, Mrs. Reyes! I wanted to introduce myself, my name is Priyanka, and I will be your nurse today.” My client states that she is confused, and does not understand why she is at the hospital. Mrs. Reyes has been diagnosed with a urinary tract infection; when older adults develop urinary tract infections they tend to have symptoms including a sudden onset of …show more content…
Earlier during my assessment of Mrs. Reyes I learned that she does not have good eyesight, and does not wear her eyeglasses anymore. Therefore, told her that I will talk with the social worker about setting up an appointment with the Ophthalmologist who is covered by her insurance, in close proximity to her house, to ensure that she regularly gets her eyes checked, gets a new pair of eye glasses, and is educated on the importance of eye exams to prevent retinopathy. When the PCA told me Mrs. Reyes’s vital signs, the first thing I noticed was that her oxygen level was 88% on room air that is a bit low. Therefore, I went back in, reassessed our patient and noticed she needed a boost in bed. After boosting I checked her pulse ox, and it had gone back within normal limits above