ARIZONA STATE UNIVERSITYCOLLEGE OF NURSING

NUR 320 Long Term Care (LTC) Clinical Prep Form

STUDENT NAME: Rebecca Clopp DATE: 11/18/10

CLIENT INITIALS: D.P. AGE (unless > 89): 87 GENDER: F MARITAL STATUS: Widowed

ADVANCE DIRECTIVES (i.e. DNR): DNR, LW, MPOA

PAYMENT SOURCE: Medicare, Social Security, AR AARP BC of Illinois ALLERGIES: PCN, NSAIDS, Vicodin, Pollen, No ABT for URI

MEDICAL HISTORY:

- Senile Dementia with Depression- Chronic Low Back Pain- Peripheral Neuropathy- Type II Diabetes-Insulin Dependent *Surgical- Coronary Artery Bypass Graft- Depression - Joint right hip replacement- History of recurrent UTIs *Family Medical Complications- Arrhythmia- Other idiopathic peripheral neuropathy - Type II Diabetes- GERD - GERD- Gastroparesis - Osteoporosis- Mouth Pain- Postmenopausal atrophic vaginitis

TEXTBOOK DESCRIPTION OF HEALTH PROBLEMS

1. Senile Dementia with DepressionDementia and depression are two of the three most common cognitive problems in adults. Dementia is characterized by dysfunction or loss of

memory, orientation, attention, language, judgment, and reasoning (Lewis, 2011). It is usually diagnosed when two or more brain functions are significantly impaired. Dementia is not a disease, but rather it is a group of symptoms that may be caused by a disease or some other condition such as Alzheimers. The initial symptoms of dementia are most commonly related to cognitive functioning, and are usually noticed and reported by family members. The most common causes of dementia are neurodegenerative conditions and vascular disorders. Depression is characterized by sadness, difficulty thinking and concentrating, fatigue, apathy, feelings of despair, and inactivity. In severe depression poor concentration and attention can occur and cause memory and functional impairment. Dementia with depression occurs in 40% of patients with dementia, and when they occur together intellectual deterioration can be extreme (Lewis, 2011).

2. Chronic Low Back PainChronic low back pain is characterized as pain in lower back that lasts more than 3 months or recurrent episodes of pain that are

incapacitating (Lewis, 2011). It may be caused by a degenerative disk disease, prior injury, obesity or lack of physical exercise, systemic disease, structural and postural abnormalities, or osteoarthritis. Osteoarthritis is most commonly found in people over 50, and usually affects the lumbar spine, although it may occur in the thoracic spine in younger patients. Spinal stenosis occurs in osteoarthritis and causes narrowing of the vertebral canal or nerve root canals through bone movement into those spaces. Lumbar spinal stenosis causes pain initially in the lower back, but that pain may radiate into the legs and buttocks. The pain may worsen with walking, or standing for a period of time. Relief of pain can come from medication, rest, local heat or cold application, weight reduction, or keeping active and exercising to keep joints mobile. Antidepressants may also help with pain relief and sleep problems (Lewis, 2011).

3. Peripheral NeuropathyPeripheral neuropathy may be attributed to traumatic injuries, infection, toxin exposure, or metabolic problems such as diabetes. The

primary symptoms include numbness and pain in the hands and feet, and are described as a tingling or burning feeling, or sometimes a loss of sensation. The pain or numbness is a result of nerve damage. Because peripheral neuropathy is usually caused by an underlying condition, the symptoms may improve with time if the condition is treated for. Also there are many reliable medications to treat the conditions of the neuropathy. Peripheral neuropathy may affect three types of nerves including sensory nerves which affect sensation, motor nerves which affect muscle movement, and autonomic which control blood pressure, heart rate, digestion, and bladder function. Damage to these nerves may cause numbness or tingling in your lower and upper extremities, burning or sharp pain, sensitivity to touch, muscle weakness or paralysis, lack of coordination, and bowel or bladder problems Mayo Clinic Staff, (2011).

FOCUSED HEALTH ASSESSMENT SYSTEMS

FOCUSED HEALTH ASSESSMENT SYSTEM: RATIONALE FOR SELECTION:

1. Musculoskeletal D.P.’s chronic low back pain and right hip replacement have caused her legs to become weak, and ability to walk highly impaired. She is at risk for osteoporosis, and in observing her unsteady gait it is apparent that she is at risk for falls especially because she is not cognizant of her decreasing physical capabilities.

2. Neurological When performing PERRLA on D.P. during the bedside basic, she was unable to focus on my pen. Her peripheral neuropathy has attributed to her unsteady gait, which influences her walking.

Also her dementia is due to a neurodegenerative condition that is impairing her cognitive abilities.

NURSING DIAGNOSES

1. Chronic confusion related to loss of memory secondary to dementia as evidenced by disorientation and impaired judgment.

2. Impaired comfort related to chronic low back pain secondary to right hip replacement as evidenced by patient reports pain in her legs after walking a short distance.

3. Hopelessness related to lack of responsibility for decisions and life as evidenced by patient stating, “I gave my daughter everything of mine so now she makes decisions for me and my life”. and “I just do what they tell me to do.”

4. At risk for falls related to impaired mobility, unsteady gait, tremors in legs, and impaired judgment.

5. At risk for ineffective self-health management related to barriers to comprehension secondary to cognitive deficits, and memory problems.

MEDICATIONS List in sequence of time of administration.

Include all routine medications and any PRN medications administered in the past week.

Time Drug (generic & Trade name) /prescribed dosage/route

Usual dosage range

Drug Classification Rationale for taking(specific to your client)

Nursing Implications/ Client Teaching

Indicate rationale if medication places client at risk for fall.

0800-2000

Acetaminophen (Tylenol) 2 tabs po BID *also noted prn

325-650mg q 4-6hr

Antipyretics, Nonopoid analgesics

Pain, Fever -Asses for pain –Take medication exactly as directed and no more; excessive use may lead to hepatotoxicity -Avoid alcohol, 3 or more glasses a day increases the risk for liver damage –Avoid taking with salicylates or NSAIDS –May alter results of blood glucose monitoring –Avoid taking more than one product containing acetaminophen at a time to prevent toxicity –Contact your health care provider if fever is greater than 103F or last longer than 3 days

2000 Donepezil (Aricept) po daily 23mg

5-10mg/day Anti-Alzheimer’s agents

Dementia -Do not take more than prescribed –Missed doses should be skipped –Emphasize the importance of taking daily –Inform that it may take weeks before improvement –Caution for dizziness –Notify doctor if nausea, vomiting, diarrhea, or changes in stool color occur, or if new symptoms or previous symptoms intensify –Monitor progress of behavior

0800-1700

Cranberry cap 200mg po BID 300-400mg twice/day

Supplement Urinary prophylactic -Can cause stomach upset, and diarrhea –Can increase the risk for kidney stones –Do not take with Warfarin, or any medication that are changed and broken down by the liver

0800-1200-2000

Gabapentin (Neurontin) 100mg po TID

300mg-3600mg/day

Analgesic adjuncts, anticonvulsants, mood stabilizers

Neuropathy -Should not exceed 12hr between doses –Do not double dose, take missed dose as soon as possible if less than 2hr till next dose –Do not take within 2hr of an antacid –May cause dizziness and drowsiness; avoid driving or activities requiring alertness until response to medication is known –Notify doctor if thoughts about suicide, or unusual changes in behavior

2000 Insulin Glargine (Lantus) 100U/mL subcut daily

67U Hormones Diabetes Mellitus -Monitor blood sugar –Risk for kidney or liver disease –Limit alcohol intake –Do not use when you have low blood sugar –Monitor lifestyle and activity changes –In times of stress consult your doctor for a change in treatment plan –May experience blurred vision,

dizziness, or drowsiness0500-1130-1630

Metoclopramine (Reglan, Motozolv ODT) 5mg tab TID

10-15mg 30 min ac and at bedtime (not to exceed 0.5mg/kg/day). Some pt may repond to doses as small as 5mg

Antiemetics Dyspepsia -May cause drowsiness, dizziness, tiredness, trouble sleeping, agitation, headache, and diarrhea –Notify doctor for mood changes, muscle spasms, decreased sexual ability, tremors, swelling of hands or feet, abnormal breast-milk production –May cause tardive dyskinesia; watch for unusual uncontrolled movements

0800 Multivitamin tab po daily 1/day Vitamins Vitamin deficiency prevention

-Avoid in patients with alcohol intolerance, hypersensitivity to preservatives, colorants, or additives -May have urine discoloration

0800-2000

Mematine (Namenda) 10mg po BID

5-15mg/day Antialzheimer Dementia -Use cautiously in renal impairment, with use of other NMDA antagonists –Watch for alkaline urine –May cause dizziness, fatigue, headache, sedation, hypertension, rash, weight gain, urinary frequency, and anemia –Improvement in cognitive function may take several months, and degenerative process is not reversed

0800 Ranitidine (Zantac) 150mg tab po daily

300mg/day Antiulcer GERD -Assess for epigastric or abdominal pain, blood in stool, emesis, or gastric aspirate –May cause false-positive results for urine protein test with sulfosalicylic acid –Administer with meals or immediately after and at bedtime –Avoid excessive alcohol –May cause drowsiness or dizziness –Inform pt medication may temporarily cause stools and tongue to appear gray black

1700 Risperidone (Risperdal) 0.25mg 1/2tab po daily

0.25-4mg/day CNS agent, antipsychotic, atypical

Behavior Therapy -Do not engage in hazardous activity until response to drug is known –Be aware of the risk of orthostatic hypotension –Wear sunscreen and protective clothing to avoid photosensitivity –May cause drowsiness, headache, insomnia, agitation, extrapyramidal symptoms, orthostatic hypotension –Increased risk for stroke and heart failure

2000 Senna Plus (Senna, Senokot) 2tabs po daily

30mg/day at night

Herbal Constipation -Tell your doctor if you have a sudden change in bowel habits that lasts longer than 2 weeks, bleeding from the rectum, intestinal blockage

0800Sertraline HCL (Zoloft) 100mg tab po daily

50-200mg/day Antidepressant SSRI Depression -May cause dizziness, drowsiness, fatigue, headache, insomnia, tinnitus, anxiety, emotional liability, weakness, palpitations, constipation, dry mouth, nausea, tremor –Avoid CNS depressant drugs or alcohol –Frequent mouth rinses or sugarless gum for dry mouth –Wear protective clothing when exposed to sunlight –Check for respiratory

depression –Assess for suicide0800 Vitamin D 1,000 U 2tabs daily 400-2000

IU/dayVitamin Bone Health -May increase calcium levels and increase the risk for

kidney disease –Watch for atherosclerosis

EVALUATION OF DRUG THERAPY

DRUG EXPECTED OUTCOME(What would you expect to happen with use of this drug?)

CLIENT RESPONSE(What kind of signs and symptoms did the client exhibit in response to the medications?) *Assess your client before & after giving medications (when possible)Record assessment (subjective and objective data) below.

Acetaminophen Decrease in pain and fever. No fever. Pt states pain in right arm before medication was given. Pt states the pain is manageable, and controlled by the medication. After medication is given, pt states pain is in the legs. Pt is confused toward which leg is hurting, and the quality of her pain. Pain is observed at a 3.

Multivitamin Look for any vitamin deficiencies. Pt shows no signs of vitamin deficiencies.

Cranberry Asses for urinary frequency. Pt has regular urination throughout the day.

Gabapentin Relieve of nerve pain. Pt had no report of headaches before or after the medication was given.

Vitamin D Assess for bone pain, look for signs of weak bones. Pt did not report any bone pain, but is at risk for falling and breaking bones.

Metoclopramide Should control heart burn, decrease symptoms of nausea, vomiting, and stomach fullness. Speeds up emptying and movement of upper intestines

Pt did not complain of any chest pain before or after medication was given. When asked about general chest pain, she had no memory of having chest pain. Pt did not report any symptoms of nausea and none were observed

Namenda Improve memory, awareness, and the ability to perform daily functions.

Pt was alert and aware before and after medication was given.

Ranitidine Relief of heartburn and stomach pain. Pt did not report any heartburn or stomach pain before or after medication was given.

Sertraline HCL Mood stabilizer. Assess for depression. Pt was content before and after the medication was given, but later in the day stated she felt lonely.

Deglin, J. H., Vallerand, A. H., Sanoski, C. A. (2011). Davis’s drug guide for nurses. (12 ed.) Philadelphia: Davis Company.

HEALTH PATTERNS ASSESSMENTConcept Map

Nutrition Metabolic (+)S: Pt describes her appetite as good, and reports no changes in her diet.(+)S: Pt reports no heart burn, and is on medication for her GERD. (+)S: Pt says she drinks alot of water throughout the day, coffee in the morning, and milk or prune juice in the afternoon.(+/-)S: Pt says she eats anything and has no food restrictions, but she is a type II diabetic. (+)O: Pt is taking calcium, a multivitamin, and cranberry capsules. (+)S: Pt states she heals well. (+)S: Pt reports no problems with her teeth or gums.(+)O: Temperature 98.6F(+)O: Pt skin color is flesh colored with even pigmentation. No lesions, edema, erythema, or varicosities present. Even hair distribution. (-)O: Pt has mild bruising on right arm from lifting herself up. (+)O: Pt skin is skin is dry, warm to touch.(-)O: Pt at risk of malnutrition with a score of 21 on the nutritional assessment due to psychological stress in the past 3 months. (+)O: Pt is not at risk for a pressure ulcer. (-)O: Pt cannot protrude jaw, and is a 3/5 in her TMJ strength.(-)O: Pt has peripheral neuropathy. (-)O: Pt is a type II diabetic and is insulin dependent.

Elimination(+)S: Pt states she has no issues with her ability to urinate, and feels her pattern is average. (-)S: Pt states she is constipated, and taking medication for it which she feels is helping. (+)O: Pt’s abdomen is flat, no lumps, or pulsations. No

pain or tenderness. Bowel sounds present in 4 quadrants.

Sleep and Rest (+)S: Pt states she goes to bed at 9:00 pm and wakes up at 6:00 am, feels rested during the day, and takes no sleeping aids.(+)S: Pt states she does not take naps.

(-)S: Pt says she doesn’t know what she does to relax, she just goes to sleep and does what they tell her to do.Self Perception Self Concept

(-)O: Pt had difficulty describing herself, and seemed confused at what to say about herself.(+)S: Pt states that she does what she wants, and has small demands which are things she likes about herself.(+)S: Pt states she wouldn’t change anything about herself, and if she felt that way she would just change it.(+/-)S: Pt states she is a bit impulsive, and doesn’t really think about things but rather she just does them.(+)S: Pt is most concerned about her family and her health.(-)S: Pt reports she is lonely.(+/-): Pt states she is safe at WV, and that is why she feels she should be happy here.

Cognitive Perceptual(+)S: Pt reports no change in hearing, and she does not use hearing aids.(+/-)S: Pt states she only uses glasses when she reads, and she hasn’t noticed any change in her vision.(-)S: Pt reports pain in her legs especially her right leg, and discomfort in her right arm from pushing herself up.(+)S: Pt states the easiest way for her to learn things is through being taught them.(-)O: Pt is unable to assess the quality of her pain in her legs and is observed at a 4 on the pain scale. (-)S: Pt states she has no pain in the morning, but soreness increases in her legs throughout the day. (-)S: Pt reports pain in her hands especially her left index finger and states she has rheumatoid arthritis and the pain is a 7 out of 10. (-)O: Pt forgets to pick up her right foot while walking, and is needed to be reminded constantly. (-)S: Pt is unaware of the date, and comments it is not important here. (-)O: Pt’s gait has become very unsteady, and she has minor distress. (+/-)O: Pt is alert, maintains decent eye contact, she speaks clearly, her movements are slow, and her body position is somewhat tense due to discomfort and pain. (-)O: Pt has no corneal reflex symmetry; lacking in right eye due to some sagging in the eyelid.(-)O: Pt’s Pupils are not equal, round, do not react to light, or accommodate equal bilaterally. (-)O: Pt’s mini mental state exam score is 13 out of 30 and she is cognitively impaired. (-)O: Pt’s pupils are dilated.(-)O: Pt has senile dementia.(-)O: Pt is depressed. (-)O: Pt has chronic low back pain. (+/-)S: Pt is aware that she has some sort of cognitive deficiency as she states I can’t remember, none of us in here can remember, that’s why Im here.

Health Perception and Management (+)S: Pt considers healthy as being able to live a normal life.(+/-)S: Pt states she is in pretty good health.(+)O: Pt is able to do all self care independently, except for showering. (-)S: Pt is unable to remember when to take her medications, and which medications she is currently taking. (+/-)S: Pt feels her medications are working, but is unable to remember what her medications are for with the exception of acetaminophen. (+/-)O: Pt medications consist of vitamins, antipyretics, antialzheimers, antidepressants, analgesics, antiemetics, antipsychotics, insulin, and antiulcer drugs. (+/-)S: Pt states she is not at risk for any health conditions. (-)O: Patient is at risk for type II diabetes, arrhythmia, GERD, and osteoporosis. (+/-)S: Pt states she used to smoke and socially drink, but hasn’t done so in a long time. (+)S: Pt reports she tries to do hobbies to keep mentally healthy, such as taking bridge lessons twice a week with her friend. (+)S: Pt states she uses her walker for safety.

Values and Beliefs (+)S: Pt states her daughter is her source of strength.(+)S: Pt says she is Christian and used to go to church.(+)S: Pt states her family is most important to her.(+)S: Pt feels she has gotten what she has wanted out of life.

Sexuality Reproductive(+)S: Pt takes no hormone replacements, and has no concerns about her sexual functioning.(+)S: Pt says she used to get her pap smear regularly.

Activity and Exercise(+)S: Pt states she has no issue in limitations in her self care abilities.(-)O: Pt need help with showering, has poor balance, and has alot of trouble walking. (+/-)O: Pt uses a walker to assist her.(+)S: Pt states she participates in therapy every other day and she likes it.(+)S: Pt says she wants to be more active.(-)S: Pt states her usual daily activities are whatever they tell her to do.(+)O: O2-97% P-70bpm BP-100/60(-) Pt states her activity level is low, and she wishes it was higher.(-)O: The pt has a large nodule in the joint on her left index finger.(-)O: Pt is dependent among her walker. (-)O: Pt drags her right foot as she walks.(+)O: Pt is well groomed, dressed , and clean. (+/-)O: Pt’s heart sounds are normal rate, rhythm, S1, S2, with no S3, S4, rubs, or clicks. Gallop present. (+/-)O: Pt is relaxed, unconscious breathing. No distress, normal appearance, normal breath sounds. Minor use of accessory muscles in neck. (+)O: Pt lungs are clear to auscultation bilaterally. Regular rate and rhythm. (+/-)O: Pt’s left leg weaker 3/5 in strength for dorsal/plantar flexion. Right foot 5/5 in strength for dorsal/plantar flexion.(+/-)O: Negative Homan’s on right leg, Positive Homan’s on left leg due to overuse of the muscle. (-)O: Right hip replacement, not a full ROM. (-)O: Arthritis in hands causing pain, not a full ROM in hands especially in wrist. (-)O: Pt is at high risk for fall with a score of 7 on the fall risk model.(+)O: Pt has high independence with a score of 6 on the Katz Index.(+)O: All joints bilateral, symmetric, no gross deformities skin intact, no visible lesions or redness bilaterally; no masses, crepitus bilaterally with palpation. (-)O: Tenderness in hands, right elbow and arm, and right leg and foot. (-)O: Right ankle is swollen and discoloration in right big toe.(-)O: Not a full ROM in cervical spine, wrists/hands/fingers, hip, ankle/foot/toe, and spine.(-)O: Not full strength in cervical spine, wrist/hand/fingers, knee, ankle/toes/foot. (-)O: Pt has had a joint right hip replacement. (-)O: Pt also has tremors in her hands.(+)O: Pt always participates in the daily activities, and is never sitting for too long.

Roles and Relationships(+)S: Pt states she turns to her daughter Sandra in times of need.(-)S: Pt states no one depends on her for anything, and that she used to be a housewife and the caregiver for her family.(+)S: Pt reports she is stable financially.(-)S: Pt says she does not belong to any groups or organizations.(-)O: When asked about her husband, pt began to cry and explain her loneliness. (+/-)S: Pt reports she has given her eldest daughter Sandra everything, so that she has control and makes decisions regarding Dottie’s life.(-)S: Pt states her younger daughter used to come and visit her more often, until her daughter began to have health issues herself.(+)S: Pt states her elder daughter visits her almost everyday.

Coping Stress Tolerance(+)S: Pt states she just makes decisions and does them.(+)S: Pt says she can discuss issues if she has a problem.(+/-)S: Pt reports that when she is under stress, she just goes on living.

D.P.

SatisfactoryDeclining Controlled

Maintain

Concerning

Independent

Damaging Negatively ImpactsRealistic

Hinders

Fulfilled

HEALTH PATTERNS ANALYSIS

Evaluation of functional health patterns for normalcy (Direct links):

The Health Perception and Management pattern is declining as evidenced by the patients lengthy list of

medications, her inability to remember when to take them, what medications they are, and what they do for

her. D.P. believes that she is in pretty good health, and states she is not at risk for any health conditions, but

her medical records state otherwise.

The Nutrition and Metabolic pattern is satisfactory as evidenced by her good appetite, controlled GERD,

controlled diabetes, adequate fluid intake, good skin integrity, supplement intake, sufficient oral care, and

normal temperature. D.P. is at risk for malnutrition, but only because she has suffered from psychological

stress in the past three months.

The Elimination pattern is controlled as evidenced by the patient stating she has no issues with her ability to

urinate and feels her pattern is regular. Although she stated she has constipation, she also feels the

medication she was given for it is helping and bowel sounds are present in all four quadrants of her

abdomen.

The Activity and Exercise pattern is hindered as evidenced by the patients dependancy on her walker,

unsteady gait, rheumatoid arthritis, high risk for falls, lack of strength in her cervical spine, arms, hands, legs

and feet, and by not having the full ROM in her cervical spine, arms, hands, hips, legs, feet, and spine. Also a

possible gallop in the heart was noted, swelling in the right ankle, tremors in her hands, and some use of

accessory muscles while breathing.

The Sleep and Rest pattern is maintained as evidenced by the patient’s consistent sleep schedule, and her

stating she feels rested during the day, and she doesn’t take any sleeping aids or naps. D.P. does state she

doesn’t know what she does to relax, but that is a more cognitive issue, and she is able to fall asleep

regardless.

The Cognitive Perceptual pattern is damaging as evidenced by the patient scoring 13 out of 30 on the mini

mental exam which determines she is cognitively impaired. D.P. is also experiencing pain, but is unable to

assess the quality of her pain. The patient’s pupils are also dilated, and she was unable to respond to

PEERLA. D.P. is also dealing with depression.

The Self Perception and Self Concept pattern is concerning as evidenced by patient stating she is lonely,

and although she feels safe at Westminster Village, she feels that is the reason she should feel happy there.

D.P. does state that she wouldn’t change anything about herself, but she also had a hard time describing

herself.

The Roles and Relationships pattern is negatively impacting as evidenced by the patient stating no one

depends on her for anything, and that she used to be a housewife and the caregiver for her family. D.P. is not

part of any organizations of groups, and when asked about her diseased husband she began to cry and

explain her loneliness. The patient does have a strong relationship with her eldest daughter Sandra, but she

has also given Sandra control over her life decisions.

The Sexuality and Reproductive pattern is realistic as evidenced by D.P. stating she has no concerns about

her sexual functioning, takes no hormone replacements, and she used to get her pap smear regularly.

The Coping and Stress Tolerance pattern is independent as evidenced by the patient stating she can

discuss issues if she has a problem, she just makes decisions and does them, and she says that when she is

under stress she just goes on living.

The Values and Beliefs pattern is fulfilled as evidenced by the patient stating she feels she has gotten what

she has wanted out of life. D.P. also states her family is most important to her, and her daughter is her

source of strength.

Impact of functional health patterns on each other (Cross-links) with supporting evidence:

The Cognitive and Perceptual pattern contributes to the Self Perception and Self Concept pattern,

because the patient’s depression and dementia are creating her confused description of herself and adding to

her loneliness. The Maryland Coalition on Mental Health and Aging (2011) states that loneliness is a symptom

of both dementia and depression, but depression also “affects the way you feel about yourself.” Her memory

loss may also be contributing to the statements she makes about being impulsive, and not thinking about the

things she does. According to the Maryland Coalition on Mental Health and Aging (2011), these dementia

symptoms: “a decline in memory, thinking and reasoning skills disrupt everyday life.”

The Activity and Exercise pattern strengthens the Nutrition and Metabolic pattern due to the patient’s

independence in self-care abilities, her want to be more active, and refusal to sit for too long, she is able to

maintain her skin condition with minimal bruising and good healing. Mayo Clinic (2010) explains mobility, and

good hygiene help in protection of the condition of skin. D.P. is always well groomed, dressed, and clean

which promotes the fact that she has no problems with her teeth or gums, and stays adequately hydrated

throughout the day.

The Roles and Relationships pattern impacts the Self Perception and Self Concept pattern, because the

patient states she turns to her eldest daughter in times of need, who visits her almost everyday and is in

control of D.P.’s health decisions, and says that she is most concerned about her family and health. Also when

the client began to speak of her husband, she started crying and went into describing her loneliness without

him. Folse (2009) notes, both stressful and supportive relationships play into key roles the client assumes in

their self-concept.

The Cognitive and Perceptual pattern alters the Health Perception and Health Management pattern,

because the patient’s cognitive impairment is causing the patient to belief she is in better health and more

capable than she really is. According to the Alzheimer’s Association (2011), behaviors symptoms of

alzheimers include delusions, and these symptoms can be the most challenging and distressing aspects of

the disease. On a more positive note, D.P. understands that she has some sort of cognitive impairment so

she tries to do hobbies to keep mentally healthy such as taking bridge lessons from her friend. Another

connection is most of the medications she is taking are for cognitive problems, and she is unable to

remember when to take medications, what her medications are for, and which medications she is taking.

The Cognitive and Perceptual pattern negatively impacts the Activity and Exercise pattern because the

patient’s chronic pain is causing her poor walking ability. Jarvis (2011) explains that chronic pain can cause

stiffness, swelling, and limitation of motion in the joints, as well as cramps, weakness, and gait problems in

the muscles. The patient’s dementia is also causing her to forget to pick up her right foot which inhibits her

mobility, and puts her at a high risk for falls.

Identification of priority patterns with supporting evidence

The Cognitive and Perceptual pattern is the priority pattern for D.P. D.P.’s Cognitive and Perceptual pattern

influences the Activity and Exercise pattern, the Health Perception and Management pattern, and the Self

Perception and Self Concept pattern. The Cognitive and Perceptual pattern influences the Activity and Exercise

pattern by inhibiting the patient’s muscular skeletal capabilities. D.P.’s chronic low back pain has radiated into

her legs and feet, and according to Jarvis (2011) the chronic pain causes limitation in the range of motion and

weakness in the muscle due to disuse. D.P. has also had a right hip replacement, but her memory loss causes

her to not remember that event, and she forgets to use that joint. Because of this, she has not been able to

recover full range of motion and strength in that joint, and has began to drag her right leg. She has to

constantly be reminded to pick up her right foot while walking, but her left leg is now suffering from overuse

and has become weaker due to soreness. The most important consideration in her muscular skeletal

limitations, is her risk for falls. Cognitively she is unable to assess her capabilities, which also adds to her fall

risk. The patient’s Cognitive and Perceptual pattern also influences the Self Perception and Self Concept

pattern, because the patient states she is a bit impulsive in the sense that she doesn’t think about the things

she does, rather she just does them. The Maryland Coalition on Mental Health and Aging (2011) states that

dementia may cause a decline in thinking and reasoning, and in D.P.’s case she is really unable to assess how

she comes to a decision. The patient is also confused about who she is as a person, as she had trouble

describing herself. It seems that she has either forgot the type of person she is, or due to her situation she has

experienced a loss of herself. The Cognitive and Perceptual pattern also influences the Health Perception and

Management pattern. Interestingly, D.P. is able to understand that she has trouble with her memory, and this

works to her advantage in that she tries to keeps mentally healthy by playing bridge with her friend. I find that

it also helps her in that she is very participatory, and willing in listening to her healthcare providers rather than

becoming upset or annoyed with them. One of the potential complications for D.P. with her dementia is

delusions. She believes she is healthier than is true, and the most likely complication from this is that it could

end up putting her at risk for not using her walker and falling.

Arizona State UniversityCollege of Nursing

Health Assessment NUR 320BASIC BEDSIDE NURSING ASSESSMENT

Arizona State UniversityCollege of Nursing

Health Assessment NUR 484BASIC BEDSIDE NURSING ASSESSMENT

Client Initials:__D.P.__

Assessment DocumentationVital Signs: T, P, R, BP, pain,

OxygenationO2-97% T-98.6F P-70bpm BP-100/60 Pain- pt states no pain in the morning, but soreness has increased in legs. She is unable to assess the

quality of her pain and is observed at a 4 on the pain scale. Pt reports pain in her hands especially her left index finger and states she has rheumatoid arthritis and the pain is a 7 out of 10. Observed a large nodule in the joint on her left index finger.

General Survey Overall appearance, facial expression, activity level, behavior, gait, distress, speech, movements, body position, eye contact, alertness and orientation of time, place, person.

Pt states her activity level is low. She is unaware of the day, and comments it is not important. She is oriented to who she is and where she is. Gait has become very unsteady, and she has minor distress. She is alert, maintains decent eye contact, she speaks clearly, her movements are slow, and her body position is somewhat tense due to discomfort and pain. Overall she is well nourished, and well groomed.

SkinInspect over entire body surface as exposed and as needed including: color, lesions, visible edema, erythema, varicosity, hair distribution. Palpate skin for moisture, texture, and temperature with back of hand all skin surfaces as needed.

Color is flesh colored with even pigmentation. No lesions, edema, erythema, or varicosities present. Even hair distribution. Mild bruising on right arm from lifting herself up. Skin is dry, warm to touch.

Head, Face, Neck Inspect for symmetry, lumps, and neck pulsations bilaterally

Face is symmetric. No lumps or pulsations bilaterally.

EyesPERRLA direct and consensual bilaterally

No corneal reflex symmetry; lacking in right eye due to some sagging in the eyelid. Pupils are not equal, round, do not react to light, or accommodate equal bilaterally.

HeartInspect precordium for lifts, heaves, & pulsationsAuscultate aortic, pulmonic, Erb’s point, mitral areas with diaphragm & bell

No lifts, heaves, or pulsations. Normal rate, rhythm, S1, S2, with no S3, S4, rubs, or clicks. Gallop present.

LungsInspect position of breathing position and use of accessory musclesInspect quality, rhythm and pattern of respirationsAuscultate lungs all lobes bilaterally

Relaxed, unconscious breathing. No distress, normal appearance, normal breath sounds. Minor use of accessory muscles in neck. Clear to auscultation bilaterally. Regular rate and rhythm.

AbdomenInspect for contour, pulsations, lumpsAuscultate bowel sounds in 4 quadrantsPalpation light

Abdomen is flat, no lumps, or pulsations. No pain or tenderness. Bowel sounds present in 4 quadrants.

Upper ExtremitiesGrips bilaterallyCapillary refill bilaterally

Grips 3/5 equal bilaterally. Capillary refill 2-3 seconds bilaterally.

Lower ExtremitiesPushes and pulls bilaterallyDorsalis pedis & posterior tibial pulses bilatAnkle or pretibial edema bilaterallyHoman’s sign bilaterallyCapillary refill bilaterally

Left leg weaker 3/5 for dorsal/plantar flexion. Right foot 5/5 for dorsal/plantar flexion. Posterior tibial pulse, and dorsalis pedis pulse present bilaterally. No edema bilaterally. Negative Homan’s on right leg, Positive Homan’s on left leg. Capillary refill 2-3 seconds bilaterally.

Musculoskeletal Inspect joints for redness, edemaPalpate joints for warmth, tenderness, & painROM active and passive as needed (as appropriate)

No redness, edema, warmth, tenderness, or pain. Knees- rg knee surgery. No pain or clicks normal ROMShoulders, elbows, and feet normal ROM. Right hip replacement, not a full ROM. Arthritis in hands causing pain, not a full ROM in hands especially in wrist.

Bedside Neuro Assessment Note Gait if able to ambulateOrientated x3See general survey

Gait is unsteady. Pt is oriented to person and place, but not to date and time.

References

Alzheimer’s Association Staff, (2011). Managing Behavioral Symptoms. Alzheimer’s

Association. Retrived from http://www.alz.org/professionals_and_researchers_14310.asp

Deglin, J. H., Vallerand, A. H., Sanoski, C. A. (2011). Davis’s drug guide for nurses.

(12 ed.) Philadelphia: Davis Company.

Folse, V. (2009). Self Concept. In P. A. Potter & A. G. Perry (Eds). Fundamentals of

nursing. (7th ed., 410-425). St. Louis, MO: Mosby Elsevier

Jarvis, Carolyn (2011). Physical Examination and Health Assessment [6] (VitalSource

Bookshelf), Retrieved from http://pageburstls.elsevier.com/books/978-1-4377-0151-

7/id/B9781437701517000042_s0270

Lewis, Sharon (2011). Medical-Surgical Nursing (with Media) [8] (VitalSource Bookshelf),

Retrieved from

http://pageburstls.elsevier.com/books/9780323065801M/id/B978032306580110064

3_t0030

Maryland Coalition on Mental Health and Aging Staff. (2011). Dementia/Alzheimers. Mental

Health Association of Maryland. Retrieved from

http://www.mhamd.org/aging/mentalhealth/dementia.htm

Mayo Clinic Staff, (2011). Peripheral Neuropathy. Mayo Foundation for Medical Education and

Research. Retrieved from

http://www.mayoclinic.com/health/peripheralneuropathy/DS00131/DSECTION=co

mplications

Mayo Clinic Staff. (2011). Prevention. In Bedsores. Retrieved from

http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=prevention

References

Alzheimer’s Association Staff, (2011). Managing Behavioral Symptoms. Alzheimer’s

Association. Retrived from http://www.alz.org/professionals_and_researchers_14310.asp

Deglin, J. H., Vallerand, A. H., Sanoski, C. A. (2011). Davis’s drug guide for nurses.

(12 ed.) Philadelphia: Davis Company.

Folse, V. (2009). Self Concept. In P. A. Potter & A. G. Perry (Eds). Fundamentals of

nursing. (7th ed., 410-425). St. Louis, MO: Mosby Elsevier

Jarvis, Carolyn (2011). Physical Examination and Health Assessment [6] (VitalSource

Bookshelf), Retrieved from http://pageburstls.elsevier.com/books/978-1-4377-0151-

7/id/B9781437701517000042_s0270

Lewis, Sharon (2011). Medical-Surgical Nursing (with Media) [8] (VitalSource Bookshelf),

Retrieved from

http://pageburstls.elsevier.com/books/9780323065801M/id/B978032306580110064

3_t0030

Maryland Coalition on Mental Health and Aging Staff. (2011). Dementia/Alzheimers. Mental

Health Association of Maryland. Retrieved from

http://www.mhamd.org/aging/mentalhealth/dementia.htm

Mayo Clinic Staff, (2011). Peripheral Neuropathy. Mayo Foundation for Medical Education and

Research. Retrieved from

http://www.mayoclinic.com/health/peripheralneuropathy/DS00131/DSECTION=co

mplications

Mayo Clinic Staff. (2011). Prevention. In Bedsores. Retrieved from

http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=prevention