ARIZONA STATE UNIVERSITY
COLLEGE OF NURSING
NUR 320 Long Term Care (LTC)
Clinical Prep Form
STUDENT NAME: Rebecca Clopp
CLIENT INITIALS: D.P.
DATE: 11/18/10
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
Depression
History of recurrent UTIs
Other idiopathic peripheral neuropathy
GERD
Gastroparesis
Mouth Pain
Postmenopausal atrophic vaginitis
*Surgical- Coronary Artery Bypass Graft
- Joint right hip replacement
*Family Medical Complications- Arrhythmia
- Type II Diabetes
- GERD
- Osteoporosis
TEXTBOOK DESCRIPTION OF HEALTH PROBLEMS
1. Senile Dementia with Depression
Dementia 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 Pain
Chronic 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 Neuropathy
Peripheral 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.
08002000
Acetaminophen (Tylenol) 2
tabs po BID *also noted prn
325-650mg q
4-6hr
Antipyretics,
Nonopoid analgesics
Pain, Fever
2000
Donepezil (Aricept) po daily
23mg
5-10mg/day
Anti-Alzheimer’s
agents
Dementia
08001700
Cranberry cap 200mg po BID
300-400mg
twice/day
Supplement
Urinary prophylactic
080012002000
Gabapentin (Neurontin)
100mg po TID
300mg3600mg/day
Analgesic adjuncts,
anticonvulsants,
mood stabilizers
Neuropathy
2000
Insulin Glargine (Lantus)
100U/mL subcut daily
67U
Hormones
Diabetes Mellitus
-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
-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
-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
-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
-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 drowsiness
050011301630
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
1/day
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
Vitamins
Vitamin deficiency
prevention
Mematine (Namenda) 10mg
po BID
5-15mg/day
Antialzheimer
Dementia
0800
Ranitidine (Zantac) 150mg tab
po daily
300mg/day
Antiulcer
GERD
1700
Risperidone (Risperdal)
0.25mg 1/2tab po daily
0.25-4mg/day
CNS agent,
antipsychotic,
atypical
Behavior Therapy
2000
Senna Plus (Senna, Senokot)
2tabs po daily
30mg/day at
night
Herbal
Constipation
Sertraline HCL (Zoloft)
100mg tab po daily
50-200mg/day
Antidepressant SSRI
Depression
-Avoid in patients with alcohol intolerance,
hypersensitivity to preservatives, colorants, or additives
-May have urine discoloration
-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
-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
-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
-Tell your doctor if you have a sudden change in bowel
habits that lasts longer than 2 weeks, bleeding from the
rectum, intestinal blockage
-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 suicide
08002000
0800
0800
Vitamin D 1,000 U 2tabs daily
400-2000
IU/day
Vitamin
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.
Multivitamin
Look for any vitamin deficiencies.
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.
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
Namenda
Improve memory, awareness, and the ability to perform daily
functions.
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
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 ASSESSMENT
Concept Map
Nutrition Metabolic
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.
(+)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.
Declining
Satisfactory
Controlled
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.
Fulfilled
D.P.
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.
Maintain
s
Concerning
Hinders
Independent
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.
Coping Stress Tolerance
Realistic
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.
Negatively Impacts
Damaging
(+)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.
Roles and Relationships
Cognitive Perceptual
(+)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.
(+)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 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 selfconcept.
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 University
College of Nursing
Health Assessment NUR 320
BASIC BEDSIDE NURSING ASSESSMENT
Arizona State University
College of Nursing
Health Assessment NUR 484
BASIC BEDSIDE NURSING ASSESSMENT
Client Initials:__D.P.__
Assessment
Documentation
Vital Signs: T, P, R, BP, pain,
Oxygenation
O2-97% 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.
Skin
Inspect 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.
Head, Face, Neck
Inspect for symmetry, lumps, and neck
pulsations bilaterally
Eyes
PERRLA direct and consensual bilaterally
Heart
Inspect precordium for lifts, heaves, &
pulsations
Auscultate aortic, pulmonic, Erb’s point,
mitral areas with diaphragm & bell
Lungs
Inspect position of breathing position and
use of accessory muscles
Inspect quality, rhythm and pattern of
respirations
Auscultate lungs all lobes bilaterally
Abdomen
Inspect for contour, pulsations, lumps
Auscultate bowel sounds in 4 quadrants
Palpation light
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.
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.
Face is symmetric. No lumps or pulsations
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.
No lifts, heaves, or pulsations. Normal rate,
rhythm, S1, S2, with no S3, S4, rubs, or clicks.
Gallop present.
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.
Abdomen is flat, no lumps, or pulsations. No pain
or tenderness. Bowel sounds present in 4
quadrants.
Upper Extremities
Grips bilaterally
Capillary refill bilaterally
Lower Extremities
Pushes and pulls bilaterally
Dorsalis pedis & posterior tibial pulses bilat
Ankle or pretibial edema bilaterally
Homan’s sign bilaterally
Capillary refill bilaterally
Musculoskeletal
Inspect joints for redness, edema
Palpate joints for warmth, tenderness, &
pain
ROM active and passive as needed (as
appropriate)
Bedside Neuro Assessment
Note Gait if able to ambulate
Orientated x3
See general survey
Grips 3/5 equal bilaterally. Capillary refill 2-3
seconds 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.
No redness, edema, warmth, tenderness, or pain.
Knees- rg knee surgery. No pain or clicks normal
ROM
Shoulders, 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.
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/978-1-4377-01517/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/978-1-4377-01517/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