Clinical NCP Project (Part 3 Assessment)-1 (1)

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School

Atlantic Cape Community College *

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Course

112

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Health Science

Date

Oct 30, 2023

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PATIENT’S VITAL SIGNS T: 97.5 F P: 73 R: 21 BP: 129/79 Pox: 93% Pain level: 3/10 Location: all over. Body ache. Stated by patient. Characteristics: Achy feeling all over body 24 HOUR INTAKE/OUTPUT SHIFT: Oral/Tube Feed IV Urine Emesis Tubes/Drainage Liquid BM NONE NONE NONE NONE NONE NONE Total Input: Total Output: Deficit/excess(-/+) IV ACCESS List catheter type, site, date inserted and flush requirements #1 #2 #3 #4 Type Site Date Inserted Flush CVC-Central Venous Catheter, P=Peripheral, IP=Infusaport, IDC=Intradialytic Catheter, PICC=Peripheral Intravenous Central Catheter, S= Saline Lock SKIN Color: Temp: Moisture: Turgor: Pale pink Cool Dry/brittle >5 secs Wounds/Incisions/Rashes (identify location of each on the diagrams and number them. Give them a full description: Location : Measurements : Description : Pressure Ulcer Risk Scale (See Braden Scale on next page): 3 List Integumentary Problems with full descriptions 1. sssss

BRADEN SCALE - For Predicting Pressure Sore Risk Date 08-08-22 2 2 2 3 1 12 High risk 4 Low Risk 15-18; Moderate Risk 13-14; High Risk 10-12; Severe Risk <9 Total Score

NEUROLOGICAL General Survey: Appearance Well groomed. Friendly pleasant behavior/demeanor Posture: Frail. WBAT Behavior: pleasant and friendly. cooperative Level of Consciousness: Ax1 Lethargic: aroused by moderate stimuli. Drifts back to sleep. Other: Progressive dementia. Forgetfulness and confusion. Glasgow Coma Scale Points Date Date Date Best Eye Opening Spontaneous--open with blinking at baseline  To verbal stimuli, command, speech  To pain only (not applied to face)  8/8/ No response  Best Verbal Response Oriented  Confused conversation, but able to answer questions  Inappropriate words  8/8/ Incomprehensible speech  No response 1 Best Motor Response Obeys commands for movement 6 Purposeful movement to painful stimulus 5 Withdrawals in response to pain 4 Flexion in response to pain (decorticate posturing) 3 Extension in response to pain (decerebrate posturing) 2 8/8/2 5

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2 No response 1 Total 7 Oriented: Person X Place Time Intermittently confused X Pupils: 2 mm Speech: Clear X Soft spoken Other Sensory Deficits: Hearing X Deaf Vision loss X Blind Smell Taste Assistive devices: Hearing Aid X Glasses X Other: Hand grasps: Equally strong Weakness X 3 R 2 L Leg strength: Equally strong Weakness X 1 R 1 L Further description: patient was diagnosed with muscle deterioration disorder HEAD and NECK Eyes: Drainage Redness Extraocular movement Ears: Drainage Redness Other: Nose: Drainage Redness Other: Mouth/Throat : dry. Plaque buildup on bottom Redness X Bleeding Lesion s Other: Further description: top dentures. Bottom shows signs of plaque build up (#20-28) CARDIOVASCULAR Heart Rate: 73 Rhythm: +2 x Regular Irregular Cap Refill: <5 sec Chest Pain Neck Vein Distention Edema Site: Pitting x Nonpitting Peripheral Pulses: Grade: Thready, +1 Weak, +2 Normal, +3 Bounding Radial L: 2 R: 1 Pedal L: 2 R: 1 Other L: R: Site: Further Description RESPIRATORY 6

Rate: 21 x Rhythm: Regular Irregular Depth: Normal Shallow Deep Orthopnea x Apnea Other: Lung Sounds: Right - clear Left - clear O 2 Type/Flow rate: NONE Resp Tx: Albuterol arousal PRN O 2 Sat: 93 Cough: Nonproductive Productive Sputum: Further Description: GASTROINTESTINAL (GI) Abdomen: Soft Flat x Obtuse Distended Nondistended x Pain (0-10) 0/10 Nausea Vomiting Bowel Sounds: non active Incontinence: Y/N : mixed incontinence Last BM: 8/8/22 Stool Characteristics: small. Light beige. Soft. Tubes/Ostomy None NUTRITION Weight on Admission: Current Weight: Diet: reg diet. Sugar sub Restrictions/Modifications: sugar substitute Condition of Teeth: natural bottom signs of plaque-build (20-28) Dentures: Top x Bottom Appetite: Good Fair x Poor Feeding Assistance x Difficulty Chewing Dysphagia Thickened Liquids Nectar Honey Pudding % of Meals Eaten:90 Breakfast x Lunch Dinner Snacks Tube Feeding: Site: Type/Rate Further Description: GENITOURINARY (GU) Urine: Color: lite amber Clarity: incontinent Odor: 7 x

Problems: Burning Urgency Difficulty Dysuria Incontinence x Output: Adequate Inadequate Pertinent Sexual Hx: unknown Monthly-self Exam (testicular/breast) Y/N: unknown Contraceptive Use: Further Description: MOBILITY/Musculoskeletal Gait: frail. Weak posture. 2x assist. ROM: WBAT. LE: weak, bilateral Fatigue x Contractures x Paralysis Turns Self in Bed Assistance Needs: Bathing x Dressing x Toileting x Ambulating x Hx of Falls x Fall Risk Score (See Next Page): 95 high risk Assistive Devices: x Wheelchair x Walker Cane Other: bed/WC alarm Physical Therapy: WBAT. PT 3x weekly. Further Description: Fall Risk Assessment Morse Fall Risk Scale 8 It e m It e m S core P atie n t S core 1. History o f falling (immediate or previous ) No 0 Yes 25 - - -25 2. Sec on dar y di a g n o sis ( ≥ 2 medical diagnoses in chart) No 0 Yes 15 - - -15 3. Ambulatory aid None/ bedrest / nurse assist Crutches/cane/walker Furniture 0 15 30 ---15 4 . I ntravenous therapy/ hepar i n lock No 0 Yes 20 - - - 5. Gait Normal/ bedrest / whee l chair Weak* I mpaired** 0 10 20 -20 - - 6. Mental status Oriented to own abi li ty Overestimates / forgets limitations 0 15 ---15 Tot a l Score: Tally the patient score and r ecord. < 25 : Low risk 25 - 45: Moderate risk >45 - -90 High risk -

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* Weak gait: Short steps (may shuffle), stooped but able to lift head while walking, may seek support from furniture while walking, but with light touch(for reassurance). **Impaired gait: Short steps with shuffle; may have difficulty arrising from chair; head down; significantly impaired balance, requiring furniture, support person, or walking aid to walk. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html Pain/Discomfort Location: as stated by patient, all over body Intensity (Scale of 1-10) 3/10 Quality: none Onset: none Duration: none Factors that increase pain: muscle deterioration disease. Lack of mobility Factors that decrease pain: pain medications Further Description: SOCIAL SUPPORT/PSYCHOSOCIAL Relationship with family: family involved in therapy. Client confused, cannot recollect details of family. Stress Management/Coping: participates in facility’s activities. Major Challenges/Traumatic Loss in the Last 12 Months: confusion. Forgetfulness Cultural Practices/Needs: N/A Religious/Community Resources Used: N/A Counselor/Agency Help: N/A Barriers to Learning: Pain Anxiety X Cognitive Literacy Language Cultural Deafness Blindness Other: Further Description: SELF PERCEPTION/SELF CONCEPT: Description and Feelings Regarding Self: could not state. Pt in state of confusion. Body Changes/Adjustment Problems: decrease in health due to Dx. Positive/Negative Feelings: positive attitude, 9

Further Description: COMMUNITY/HOME ASSESSMENT Highest Level of Education: N/A Current Occupation/Retired Occupation: N/A Source of Income: unemployed. Needs Assistance w/: Transportation x Shopping x Other: Home: Owns Rent Heating/Air Cooling Stairs Phone Location of Bathroom/Bedroom: N/A Safety/Medic Alert Devices: bed & WC alarms due to fall risks. Developmental Stage According to Erikson – Discuss if patient is in a positive/negative state; Explain why. Erikson stage of development: old age. Integrity vs despair. Pt was in a positive overall attitude and behavior. Pt remained friendly and helpful during assessment and care. When asked about personal life details, the patient could not remember. 10