[Expert Solution]: Documentation Scenario #2 Mrs

Documentation Scenario #2 Mrs. Ada Green, an 89 year old widow, lives alone in her two story home. She is recovering from surgery following an anterior resection for bowel carcinoma. She was discharged with a Home Nursing Care referral for a home transition assessment and wound healing assessment because she developed a post surgical wound infection while she was in hospital. At discharge from hospital Mrs. Green was alert and determined to remain independently mobile in her own home for as long as possible. Mrs. Green has Meals on Wheels delivered twice weekly and private home support twice weekly for assistance with personal care. She is on a regular diet and is capable of managing her cardiac, pain and antibiotic medications, which her friend has labelled for her. A neighbor assist with transportation, shopping and social planning. Mrs Green has no family in town. On the morning of October 12 at 0950, three days after being discharged from hospital, Janie, the Home Care Nurse, found Mrs Green sitting in her chair looking anxious and somewhat unkempt. She was rocking back and forth, clutching her abdomen and moaning. When asked she stated min paint and can’t seem to catch my breath: Her dressings were in disarray, there was a distinct fecal odor, and she was diaphoretic. She admitted that she had spent the night in her rocker, did not know the time and could not recall when shed test.taken her pills or eaten. Janie took her vital signs and they were as follows: Temperatures 38 degrees Celsius, pulse 110 minute and regular, blood pressure 100/70 mmHg, respirations 28 breaths/minute and mildly labored Assessment data Subjective Objective Nursing Diagnosis Expected Outcome