[Expert Solution]: What should the nurse notice from this…

What should the nurse notice from this case and what is the clinical significance? “Gladys Parker is a sweet little 92-year-old lady. She’s here because she had a fall at her nursing home that they think was due to dehydration and weakness. She was admitted by the night float but Dr. Howard will probably be her attending. She’s DNR/DNI. Alert to self and place, but definitely disoriented to time and situation. She’s really forgetful and doesn’t seem to want to bother anyone so she hasn’t used her call light all night. I’d guess she’s at least an assist of one for transfers. She’s on telemetry because her electrolytes were off when she arrived. EKG showed Afib with a heart rate in the 90s. Blood pressures are pretty soft, her systolic blood pressures were in the low 90s for me. Lungs are clear, she’s on room air. They put her on a mechanical soft diet. She takes her pills whole in pudding or applesauce. The nursing home said her last bowel movement was 3 days ago and that she’s incontinent of both bowel and bladder. Her urine seems really concentrated and has a strong odor. I noticed that there is still an outstanding order to collect a UA but I couldn’t get one since she was incontinent all night. Maybe you can address that with the doctor today if they still want it. She’s got a 22 gauge in her left wrist with LR running at 100 mls/hr for a total of one liter. I started that at 0200.”