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MedicationsPATIENTASSESSMENTSTUDENT: Jaime Montelione Date of Care: 5/14/18Client Initials: MB Age: 77 Gender: MaleResuscitation Status: DNR Allergies: Heparin, Iodine & Shellfish Reason for Admission: Long term care due to Dementia Medical Diagnoses: DementiaPathophysiology: “Dementia is a symptom of a variety of specific structural brain diseases as well as several system degenerations. Alzheimer’s disease presently is the commonest cause in the developed world, causing a cortical-subcortical degeneration of ascending cholinergic neurons and large pyramidal cells in the cerebral cortex. Clinically, the disease reflects predominantly deterioration of function in the association cortex. Pharmacologically and pathologically, abnormalities are more diffuse and extend into sensorimotor cortical areas as well. Dementia is a symptom and neither its pattern nor, inmost instances pathophysiology can be fully understood, we must first come to a particular cause” (Plum, F. 2018). Surgeries/ Procedures and Dates: 2012 Left knee replacement, 2014 placement of pacemaker Past medical history: Kidney stones, Gerd, diabetes Current Orders:Diet: Regular diet, thin consistency, finely chopped Activity: Out of bed to wheelchair Intake: N/A Output: N/A, Accu-Checks: finger sticks daily Vital signs: 5/14/18- BP 132/84 Right arm, HR 80bpm, RR 15bpm, T 98.8°F tympanic, SPO2 98% Right index finger5/21/18- BP 130/84 Right arm, HR 81bpm, RR 16bpm, T 98.7°F tympanic, SPO2 99% Right index fingerDrug changes/wound care: N/AFoley: N/A NG/G-tube/PEG/PEJ: N/AIV: N/A Reason for IV: N/AOther orders: Blood work every 2 months or as needed. Check weights daily Most recent ImagingFindings:(CXR? CT? MRI?)Type of Imaging (X-Body Area ImagedReason for testing and results of test
MedicationsRay, CT, MRI, etc.)Chest, 2 views (x-ray) 4/1/18ChestReason: Position of pacemaker. Results: Heart slightly enlarged, the mediastinum normal. Right lower lobe atelectasis. Pacemaker in position. Most Recent Significant /RecentLabResults:(Chemistry? Hematology? Drug Levels? Coagulation tests?)DateLab TestResultsNormsComments4/14/18WBC count11.3 K/CU.MM3.5-11.0High; could indicated an infection or immune system disorder4/14/18RBC, count4.1 M/CU.MM3.3-4.9Within range (normal)4/14/18Hemoglobin10.0 g/dL10.7-15.1Low; Anemia 4/14/18Hematocrit3132-46Low 4/14/18Sodium143 mMOL/L135-145Within range 4/14/18Potassium3.8 mMOL/L3.5-5.3Within range 4/14/18Chloride102 mMOL/L98-107Within range 4/14/18Neutrophils72.3%55.0-70.0High; slightly high 4/14/18Glycohemoglobin7.7 H <5.7 High; Diabetes Other recent, significant procedures or tests (EKG, etc.)DateTestReason for testing and results of test2/23/18EKG Normal pacemaker function Based on the information on these pages and your assessment of this patient, what is your FIRST or PRIORITY concern and why?