Mr. Mark is a 53year old Male,

Mr. Mark is a 53year old Male, S: He was brought to the Emergency Department by ambulance on Wednesday , after sustaining a fall at home. Mark lives with his wife, who was not present at the time of the fall. On Mrs. mark arrival home, she found her husband on the floor and called the ambulance. Mr Mark is experiencing pain in his Left Knee, he is unable to weight bear on his left leg and is unsteady. He states he is feeling dizzy and unstable when attempting to stand upright. It is unclear if he hit his head in the fall as he states he “Felt dizzy when going to the bathroom and I think I blacked out”. B: Mr Mark past Medical History · Type ll Diabetes needing close management · Osteoarthritis in L) Knee · Peripheral vascular Disease (PVD) · Chronic Obstructive Airway disease (COPD) Social History (SHx): · Occupation Long Haul truck driver · ETOH (Alcohol) usage on a regular basis · Smoker, averages 15/20 cigarettes per day · Often consumes take away/ fast food diet as away from home regularly A: Mr Mark is 135kg and 170cm in height. Current vital signs Resp 17, O2 Sats 96% on room air (RA), BP 150/100, HR 99, Temp 36.9, BGL 7.8mmol/L , GCS 15. R: Further orders include; X-Ray of L) Knee shows significant advancement of Osteoarthritis, requiring further investigation, pain score is currently 8/10, Endone 10mg administered orally for pain relief at 10 pm with little effect, neurovascular observations commenced and GCS score currently 15. Further investigation of Osteoarthritis in L) knee needs to be arranged. Referrals for the Physiotherapist, dietician, social worker, diabetic educator and endocrinologist are to be arranged via eMR (electronical medical record). Regular pain relief as charted · 2/24 Vital signs · 2/24 Neurological observations · 2/24 neurovascular observations on L) leg · Non weight bearing on L) Leg · Full assistance with ADL`s · TED`s to be applied On Sunday at 13:42hrs, you are about to leave to have your lunch break when Marks wife calls you from the corridor and states “Nurse! My husband does not look well and something is wrong with him. Please can you come and have a look at him?” On entry to room, you notice mark the following: · His breathing is short and shallow · Pale and clammy skin with cyanosis around his lips and peripheral extremities · His eyes are closed and not opening when you call his name; they open when you apply pressure to his chest · He is confused and not making sense · His best motor response is localising · He is lying in a supine position at a 60% angle · Vital signs RR: 9, SpO2: 74% Room Air, BP: 100/60, HR: 45, Temp: 38.7 · BGL 1.9 mmol/L · GCS 12 : At the end of your shift you need to complete nursing documentation to record the care you provided to Mark Using either a Head to Toe Assessment Entry or Systems Entry, document the care provided to Mark below. Consider the following: Vital signs and any clinical observations Any potential nursing diagnoses Any identified safety concerns Nursing Assessments performed What interventions which were performed Identification of any problems which were outside the EN’s scope of practice Were any nursing assessment forms you completed Members of the multidisciplinary team you engaged or referrals you made Utilizations of medical terminology and appropriate language Reference https://www.svhm.org.au/images/UserUploadedImages/763/Systems-Approach-to-Documentation.jpg Please do progress note in a Systems Entry format using the following headings: CNS & pain CVS neurovascular respiratory renal GIT Metabolism Mobility ADL Skin integrity Psychological Discharge planning Please start with a short introduction about what happened to Patient and the time it occurred. SCIENCE HEALTH SCIENCE NURSING NURSING NCP106

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT AND SEND IT TO YOUR EMAIL BEFORE YOUR DEADLINE. OUR PAPERS ARE PLAGIARISM FREE*******."