Client is a 72-year-old female experiencing morning headaches and nose bleeds for several days at home. Client experiences occasional insomnia and reports the nose bleeds occurring early in the day. Client was seen by the primary health care provider who admitted the client for evaluation and medication treatment. Admission Assessment(1)/(24) 1500 Neurologic: awake, alert, oriented; pupils equal and reactive to light and accommodation; hand grasps equal Cardiovascular: apical 88 beat(s)/(m)in and regular; peripheral pulses bilaterally equal and present; no neck vein distention; capillary refill 3 seconds; no peripheral edema Respiratory: breath sounds clear and present bilateral lung fields; distant at the lung bases bilaterally; no cough Musculoskeletal: ambulates with a walker; moves all extremities independently Gastrointestinal: bowel sounds present but distant x 4 quadrants; abdomen soft, slightly distended; denies discomfort upon palpation Vital Signs(1)/(24) 1500 Temperature: 98.8oF (37.1oC) Pulse: 92 beat(s)/(m)in Respirations: 18 breath(s)/(m)in Blood Pressure:( 196)/(118) mm Hg Pulse Oximeter: 97% on room air Height: 5 ft 4 in. (64 inches) (162.56 cm) Weight: 155 lb (70.5 kg) Body mass index (BMI): 26.6 History and PhysicalOsteoarthritis x 10 years Chronic bronchitis x 5 years Occasional insomnia x 2 years
[Answered]: Client is a 72-year-old female experiencing…
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