Psychosocial assessment
• Ability to Communicate speaks clearly, lively vocabulary, initiates conversation, responds appropriately, English language
• Appearance-Frail appearance, unbathed, with slight urine odor. No make up. Wearing hospital gown.
• Behavior-watching television most of day. Talked some about dreading reentering nursing home.
• Emotional and Psychological Status. Mood is depressed with flat affect. Cooperative with nurse. Talking about how he dreads going back to nursing home.
• Socioeconomic status Talking about how he wants his daughter to come and take him to her home, but his daughter financially unable to stay home with him during day. States “I have no money to pay anyone to come to her house. That’s what I get for never saving my money. ” On Medicare.
• Spirituality States he once went to church, but now he’s not sure if there is a God.
• Sexuality Modest. No sexual overtures.
• Cultural Needs No special needs noted.
• Lifestyle- Lives in Nursing Home. States “all I ever really get to do is watch television. We play checkers sometimes. ” Retired fireman.
• Developmental level Ego integrity vs Despair I believe my patient leans toward despair. His mood is depressed and he dreads going back to the Nursing home. He states he isn’t frightened of death, but that he’s not sure of what’s on the “other side”. Seemed apathetic. His wife and siblings are no longer alive. He says his only accomplishment was to become a fireman. “My daughter doesn’t come to see me very often. ”
Physical Assessment • Neuro--Temp 97. 4 orally, AAOX 3, PERRL, Moves all extremities on command. Handgrips moderate bilat, footpresses strong bilat, responds to verbal and tactile stimuli. Admitted with TIA’s. Hx of seizure disorder. Hard of hearing.
Musculoskeletal • Fowler’s position, unsteady gait, posture straight, able to do ROM (active) all extremities, Able to groom self and transfer from bed to bedside commode, needs assistance with bathing legs and perineal area and dressing. Activity level, up with assistance. Hx of arthritis. C/O stiffness in knees.
Cardiovascular • Apical rate 88, radial 88. Regular rhythm. Blood pressure lying 130/80, standing 126/76. Cap refill <3, No EKG on chart. Radial pulses 3+ bilat, pedal pulses 2+ bilat. Hx of hypertension.
Respiratory • Rate 20, regular, equal chest wall movement, breath sounds clear bilat, No CXR on chart, PPD skin test-neg. C/O SOB with moderate exertion.
Gasstrointestinal • Abdomen soft, rounded, bowel sounds normoactive X 4, Last BM 2/13 firm brown, moderate amount. Mucous membranes moist, pink, without lesions. Gums pink without lesions or bleeding, teeth-has upper and lower dentures. Tongue pink, moist. Usual BM q day. Hx of GERD.
Genitourinary • Urine clear, yellow, without unusual odor. 8 hour output 320 cc, 24 hour output 940 cc. Voids 5 -7 times daily. Urinalysis-over Bun 13 Normal (10 -20) Creatinine. 8 (normal (. 5 -1. 5)
Endocrine • Admission blood sugar 126. Blood sugar for 2/13 113.
Integumentary • Skin color within normal limits, warm and dry. Tugor <3, texture smooth. Hair clean, thinning, scalp slightly dry in areas without scaling or redness. Nails smooth and manicured. INT R Forearm without redness or swelling.
Nutrition • Regular diet with NAS, Ate 50% breakfast, and 100% lunch. No food intolerances. Last dental exam “years ago”, Height 5’ 10”, weight 170. IBW 160 -180. Fluid intake 8 hrs po 450 cc, IV 150 cc. 24 hrs po 900 IV 350 cc. Albumin-not on chart. Total protein, not on chart, cholesterol not on chart.
Hematopoietic • Hx of anemia. CBC results 2/11/06 Pt result WBC 8. 3 RBC 5. 2 Hct 38 (low) Hgb 12. 8 (low) Platelets 138 Normal 4. 8 -10. 8 4. 7 -5. 4 42 -52 14 -18 130 -400
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