4 patients Patient 1. Gerald Adams 78-years-old: Neurological System NURSING ASSESSMENT &

NURSING ASSESSMENT & NOTES

5/6 0800

Nursing Note: Alert, oriented x 2 (person and place), disoriented to time and situation. Displays difficulty finding words. Cooperative and obeys commands appropriately. Fine tremors of hands, becomes agitated when buttoning a shirt. Shuffling gait. Reports intermittent dizziness with position changes. Trace edema in feet and pretibial region. +2 pedal pulses, radial pulses bilat.

NURSING ASSESSMENT & NOTES

1/17 1800

Neurological Assessment: PERRLA, refused to answer questions, usual shuffling gait with the walker, sometimes refusing to use a walker (poor balance noted without a walker), refuses to squeeze hands, mumbling words that are not understandable, occasional yelling and combativeness, agitated and restless.

1/18 0300

Nursing Note: The client was found ambulating in his room in the dark at 0220 without his walker. The UAP provided the walker, and the client shouted, “I don’t need that!” and continued to walk toward his door and out of the room. With assistance, the client was directed to the recliner with feet raised.

1/18 0430

Nursing Note: Found sitting on the floor near his recliner with the recliner still in the reclined position. No injuries were observed. Denies pain. VS WNL. Unable to explain the details of how he got there. Restless and agitated, hitting at the nurse. Pajama bottoms wet, refused to be changed. Able to get him back to bed with a 3 person assist. Agency policy implemented for frequent neuro checks per protocol.

VITAL SIGN TREND

Date

Temp

HR

RR

BP

SpO2

O2

1/18 0530

97.8 °F
(36.5 °C)

78

20

129/84

98%

RA

COLLABORATIVE CARE

1/17 1430

Physical Therapy Note: Mr. Edmonds easily directed, occasionally losing focus but then redirected. Orientation X 1, sometimes mentioning the facility and time of year. Discussed the use of the walker to assist in ambulation and reinforced how to use it. Demonstrated technique. Cautioned that his balance is poor and that he should use the walker to avoid falling. Became teary when discussing his wife, who died many years ago, and his need to be in a facility. Expressed gratitude, stating, “This is a nice place. I don’t have a purpose right now.” Allowed to ventilate as he told stories about his past. Escorted to the day room and appeared to be watching a football game on television.

NURSING ASSESSMENT & NOTES

4/19 0930

Nursing Note: Client is admitted to the long-term care facility for therapy. She states she just needs some help until her leg heals. She had a left tibia repair 10 days ago. Physical therapy to evaluate her later today. She was transferred from the hospital via ambulance. Both of her children are currently with her at the bedside.

4/19 0930

Neuro/Cognitive: Client alert/oriented x 4. Speech is even and clear. Pupils 3 mm PERRLA. Obeys all commands. Short and long-term memory intact.

Cardiovascular: S1 and S2 sound present. No murmurs, clicks, gallops—normal sinus rhythm on telemetry monitor in the 80s. No edema. Capillary refill less than 3 seconds.

Respiratory: Shallow breathing. Lung sounds faint/absent in RLL, crackles in bilateral bases, ineffective, moist cough. 90% on room air.

Gastrointestinal: Bowel sounds are present in all 4 quadrants. Abdomen soft, non-distended, non-tender. Last bowel movement this morning.

Genitourinary: Reports no problems or pain with urination.

Musculoskeletal: Moves all extremities freely. Has some stiffness in her hands. Lower left leg in walking boot and pain with left leg movement.