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After eight weeks of rehab therapy, a resident with post-open reduction and internal fixation (ORIF)

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Asked by oameme1

After eight weeks of rehab therapy, a resident with post-open reduction and internal fixation (ORIF) surgery is able to ambulate independently with a front-wheeled walker and manages her own ADLs. During the course of her therapy, she developed pneumonia, and daily IV antibiotics will be administered for two weeks. She also continues to receive physical therapy due to decline in mobility as a result of the onset of pneumonia. The facility has received an additional development request (ADR) for the claim period covering the antibiotic therapy.

Which of the following represents an appropriate licensed nurse’s note in support of daily skilled services for this resident during antibiotic therapy period?

a] IV antibiotic infusing in left forearm. Ambulated with physical therapy without adverse reaction. VS 120/80- 98-72-16. Medicated for pain. Tolerated meals well; no complaints of nausea.

 

b] Alert and oriented x 3. Respirations even and unlabored. Crackles in bases bilaterally to auscultation. IV antibiotics administered for pneumonia without signs or symptoms of adverse reaction. VS = 120/80 98-72-16. Ambulates to bedroom with moderate-assistance of one person, weight bearing as tolerated with front wheeled walker. Medicated for left hip pain, 6 on scale of 10, two times this shift with relief to 3/10 for 4 hours each episode.

 

c] Alert and oriented O x 3. No signs or symptoms of shortness of breath, no signs or symptoms (s/s) of respiratory distress. Transfers with assist of 1, no s/s related to adverse effects of IV antibiotics. VS 120/80- 98-72-16. Medicated for left hip pain rated 6 on scale of 10 with good effect. Patient teaching provided.

 

d] Alert and oriented. No respiratory distress. Family at bedside. Patient teaching provided. Patient able to identify medications and the potential side effects. No complaints of pain.

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 306

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