Patient 1. Gerald Adams 78-years-old: Neurological System
| 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. |
Medical History:
· Parkinson’s disease
· Mild dementia
· Congestive heart failure
· Hypertension
· Vitamin D deficiency
Home Medications:
· Carbidopa-levodopa 25 mg/100 mg by mouth twice daily
· Ropinirole 6 mg by mouth daily
· Rivastigmine 6 mg by mouth twice daily
· Amitriptyline 100 mg by mouth daily
· Carvedilol 25 mg by mouth twice daily
· Lisinopril 20 mg by mouth daily
Patient 2. Dale Carson 76-years-old: Safety System
Nursing Note: The client was unsteady this morning when rising from sitting to standing. Fall precautions reinforced. Orthostatic blood pressure readings were obtained.
VITAL SIGN TRENDDateTempHRRRBPSpO2O29/9 0955 (lying)98.1 °F (36.7 °C)78 regular20142/8298%RA9/9 0957 (sitting)98.1 °F (36.7 °C)84 regular22122/7796%RA9/9 0959 (standing)98.1 °F (36.7 °C)93 regular26105/6895%RA
Medical History:
· Parkinson’s Disease
· Mild Dementia
· Osteoarthritis
Patient 3. Jacob Edmonds 88-years-old: Sensory System
| 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. |
Medical History:
· Major neurocognitive disorder with behavioral disturbance
· Benign prostatic hyperplasia
· Hypertension
· Hyperlipidemia
Patient 4. Mary Barrett 85-years-old: Musculoskeletal System
| 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. |
Medical History: Type 2 diabetes mellitus, hypertension, hyperlipidemia, osteoporosis, and hypothyroidism
Surgical History: Left tibia repair 10 days ago, hysterectomy in 1981
Based on the provided information for each patient, here is a summarized overview and analysis:
### Patient 1: Gerald Adams, 78 Years Old – Neurological System
#### **Assessment and Notes**
– **Orientation**: Alert and oriented to person and place but disoriented to time and situation, suggesting mild cognitive impairment or dementia-related confusion.
– **Neurological Symptoms**: Difficulty finding words (suggestive of aphasia), fine tremors, shuffling gait, and intermittent dizziness, which align with symptoms commonly seen in Parkinson’s disease.
– **Physical Symptoms**: Trace edema in feet and pretibial region, with +2 pedal and radial pulses, indicating adequate peripheral circulation.
– **Medical History**:
– Parkinson’s disease (likely contributing to tremors, shuffling gait, and cognitive changes)
– Mild dementia (contributing to disorientation)
– Congestive heart failure (CHF)
– Hypertension
– Vitamin D deficiency
#### **Home Medications**
– **Carbidopa-levodopa** (used to manage Parkinson’s symptoms by increasing dopamine levels in the brain)
– **Ropinirole** (a dopamine agonist for Parkinson’s disease management)
– **Rivastigmine** (a cholinesterase inhibitor for dementia)
– **Amitriptyline** (a tricyclic antidepressant, possibly for depression or pain management)
– **Carvedilol** (a beta-blocker for heart failure and hypertension)
– **Lisinopril** (an ACE inhibitor for hypertension)
#### **Analysis**
Gerald Adams shows symptoms consistent with his medical history, particularly Parkinson’s disease and mild dementia. His difficulty with word-finding and mild disorientation suggests progression in his cognitive impairment. His physical symptoms, like tremors and shuffling gait, are characteristic of Parkinson’s disease. The presence of fine tremors and shuffling gait could affect his daily activities, such as buttoning a shirt, leading to agitation. Intermittent dizziness may be related to Parkinson’s disease or could be an orthostatic issue, compounded by his medications, such as carvedilol and lisinopril.
#### **Considerations for Care**
– **Monitor Cognitive and Physical Decline**: Regular cognitive assessments and physical therapy to maintain mobility.
– **Manage Medication Side Effects**: Evaluate for potential orthostatic hypotension and adjust medications if needed.
– **Fall Prevention**: Due to his shuffling gait and dizziness, implement fall precautions.
– **Address Agitation and Mood**: Reassess the need for amitriptyline and consider non-pharmacological interventions for agitation and mood stability.
—
### Patient 2: Dale Carson, 76 Years Old – Safety System
#### **Assessment and Notes**
– **Physical Stability**: Unsteady upon standing, with evidence of orthostatic hypotension (drop in blood pressure from lying to standing: 142/82 mmHg to 105/68 mmHg).
– **Vital Signs**:
– Lying: BP 142/82, HR 78
– Sitting: BP 122/77, HR 84
– Standing: BP 105/68, HR 93
#### **Medical History**
– Parkinson’s Disease
– Mild Dementia
– Osteoarthritis
#### **Analysis**
Dale Carson is experiencing orthostatic hypotension, a common issue in older adults, especially those with Parkinson’s disease and dementia. The fluctuation in blood pressure and increased heart rate upon standing suggests autonomic dysfunction, which can be exacerbated by medications or dehydration.
#### **Considerations for Care**
– **Monitor Orthostatic Vital Signs**: Continue to check blood pressure and heart rate in different positions to monitor orthostatic changes.
– **Fall Precautions**: Reinforce fall precautions due to unsteadiness and risk of falls.
– **Hydration and Medication Review**: Ensure adequate hydration and review medications that may contribute to hypotension.
– **Physical Therapy**: Support strength and balance exercises to reduce fall risk.
—
### Patient 3: Jacob Edmonds, 88 Years Old – Sensory System
#### **Assessment and Notes**
– **Neurological Assessment**: PERRLA (pupils equal, round, reactive to light and accommodation), but the patient is uncooperative, displaying combativeness, agitation, and refusal to use a walker.
– **Behavioral Concerns**: Combative behavior, agitation, restlessness, refusal to cooperate, and wandering (increased risk for falls and injury).
– **Fall Incident**: Found sitting on the floor without injury but confused about how he got there.
– **Vital Signs**: Stable with no signs of distress (BP 129/84, HR 78).
#### **Medical History**
– Major neurocognitive disorder with behavioral disturbance (likely contributing to agitation and poor decision-making)
– Benign prostatic hyperplasia
– Hypertension
– Hyperlipidemia
#### **Analysis**
Jacob Edmonds’ behavior suggests a progression of his neurocognitive disorder, leading to significant agitation and poor safety awareness. His refusal to use the walker and combativeness indicate a lack of insight into his physical limitations, which increases his fall risk.
#### **Considerations for Care**
– **Behavior Management**: Implement strategies to reduce agitation, such as routine scheduling, familiar environments, and minimizing stimuli.
– **Safety Precautions**: Increase supervision to prevent wandering and ensure safety.
– **Frequent Monitoring**: Continue neuro checks and frequent assessments to monitor for further decline or potential injuries.
– **Support and Engagement**: Engage in activities that are calming and can provide a sense of purpose or routine.
—
### Patient 4: Mary Barrett, 85 Years Old – Musculoskeletal System
#### **Assessment and Notes**
– **Post-Surgical Status**: Recent left tibia repair, indicating post-surgical care needs for mobility and pain management.
– **Respiratory Concerns**: Shallow breathing, absent lung sounds in the RLL, crackles in bilateral bases, and an ineffective, moist cough suggest possible atelectasis or early pneumonia.
– **Cardiovascular and Cognitive Status**: Normal cardiovascular assessment and cognitive status intact.
#### **Medical History**
– Type 2 diabetes mellitus
– Hypertension
– Hyperlipidemia
– Osteoporosis
– Hypothyroidism
#### **Analysis**
Mary Barrett’s primary concerns post-surgery are pain management and respiratory function. Her respiratory findings suggest she may be developing pulmonary complications, likely due to decreased mobility and pain restricting deep breathing.
#### **Considerations for Care**
– **Pain Management**: Adequate pain control to facilitate participation in physical therapy and prevent further complications.
– **Respiratory Support**: Encourage deep breathing exercises, incentive spirometry, and coughing to improve lung expansion and clear secretions.
– **Physical Therapy**: Begin gentle mobilization with a focus on safety, considering her recent surgery and osteoporosis.
– **Monitoring and Prevention**: Monitor for signs of worsening respiratory function or other complications related to immobility.
—
### General Recommendations for All Patients:
1. **Frequent Reassessment**: Regularly reassess each patient’s neurological, cognitive, and physical status to adjust care plans accordingly.
2. **Multidisciplinary Approach**: Engage a multidisciplinary team, including physical therapy, occupational therapy, nursing, and physicians, to address each patient’s complex needs comprehensively.
3. **Family Involvement**: Involve family members in care discussions to align care plans with patient preferences and support safety and comfort.
4. **Safety and Fall Prevention**: Implement and reinforce fall prevention strategies for all patients, given the prevalent risk factors such as Parkinson’s disease, cognitive impairment, and recent surgeries.
Each patient’s care should be individualized, emphasizing monitoring, safety, and holistic management to enhance quality of life and minimize risks.
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