make a narrative note with the provided information. please beconcise.
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Instructions 67-year-old Male (Jacob B. Bee), FULL CODE, No Known Allergies Chief complaint: having trouble with breathing feels like he can’t catch his breath, even after administering his home albuterol treatment. Vital Signs: Temp – 37.0 C, BP – 142/70, RR -24, P. 122 • Past Medical History: COPD, hypertension, BPH Neuro Assessment: A&Ox3, pupils equal and reactive at 2mm, complains of chest discomfort from having trouble breathing and has been constant Respiratory Assessment: lungs are positive for rhonchi in the left and right upper lobes and right middle lobe and diminished in the lung bases. • Cardiovascular Assessment: sinus rhythm – tachycardia, S1 and S2 heart sounds present • Gastrointestinal Assessment: Eating well, but frequently constipated • Genitourinary Assessment: has trouble with urinating at times, feels like he has to pee, but nothing comes out. Skin Assessment: no issues noted Conduct a narrative based of this information presented. Include one intervention that you could use with this patient. Please remember to include a date and time at the end of your note. Don’t forget to sign the end of the note when you are done as student nurse!!!!!
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