HEALTH ASSESSMENT

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.

1/18 0710

Nursing Note: Alert and oriented to person. Speech is clear. Strength in all four limbs is strong. Eyes PERRLA. Able to follow simple commands. Became agitated and began yelling at the UAP asked about needing to void. The nurse could direct into the bathroom, where he voided dark, cloudy, foul-smelling urine. He denied pain when urinating. Agreeable to come to the dining room for breakfast. He was using a walker.

1/18 1445

Nursing Note: Taking oral fluids and urinating. Urine is less cloudy than earlier today but is still dark and has an odor. Afebrile. He was assisted to bathroom 4x this shift. Up in the hall, he was using a walker. Pleasant with staff and less agitated but refused to go to bed for a nap after lunch. The nursing staff has been successful in redirecting when necessary.

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

1/18 0710

97.8 °F (36.5 °C)

77

20

127/80

98%

RA

intake and output

Date

Intake Source & Amount

Output Source & Amount

1/18 0730

incontinent

1/18 0800

150 mL

1/18 0900

200 mL

1/18 1015

240 mL

1/18 1030

100 mL

1/18 1200

50 mL

1/18 1230

300 mL

1/18 1330

135 mL

1/18 1400

150mL

1/18 1445

50 mL

PROVIDER PRESCRIPTIONS & NOTES

1/18 0930

Plan of Care: Goal: The client will demonstrate signs of adequate hydration with increased urine output.

Actions:

· Encourage fluids, targeting 100 mL/hour

· Toilet hourly for output measurement

· Monitor urine output and characteristics of urine

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.

1/18 0530

Medical History:

· Major neurocognitive disorder with behavioral disturbance

· Benign prostatic hyperplasia

· Hypertension

· Hyperlipidemia