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American University of Beirut Faculty of Medicine School of Nursing NURS 302- Nursing Care of Adults II Practicum Health Assessment Tool Student Information Student Name: Mohamed Sweidan Unit: 5 South Submitted to: Mrs. Silva Dekassian Patient Information Patient Room Number: 529A Age: 86 years old Primary Diagnosis: Peripheral Artery Disease Gender: Female Marital status: Married History of Present Illness and This is a case of an 86 y.o. female patient known to have multiple comorbidities ( Peripheral artery disease, diabetes, atrial fibrillation, chronic heart failure, hypertension, and end stage kidney disease), s/p left leg amputation, recent C.Defficile infection Chief Complaint Progressive left lower extremity pain with tissue necrosis bilaterally more pronounced on the left foot, decreased motor power limiting her activity Vital Signs Temperature: ˚C 36.2 HR: 89 bpm RR: 16 bpm Sp02 %: 94 BP: 154/92 mmHg Health Perception and Management Regular physical checkups Yes No Smoker Yes, packs/day: ----------------------- No Narjileh use Yes, times/week: ---------------------- No Alcohol use Yes, drinks/ week: -------------------- No Other drugs Yes, type: ------------------------------ No
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Physical Exam Findings Behavioral Behavioral symptoms Restless Agitated Aggressive Listless Incoherent speech Unclear thinking Hallucinations Excessive sleep Insomnia Fear/ anxiety Fatigue Pain Sedentary Active Neurologic Glasgow Coma Eye Opening Verbal Response Motor Response Total /15 Glasgow Coma Scale: 15 /15 Neurologic status - Conscious Lethargic Obtunded Comatose Stupor Disoriented to Time Place Person Speech Slurred Aphasia Incomprehensible Others ------------- Pupils - Reactive Non-reactive: -------------------------------- Unequally reactive Sensory - Decreased Dizziness Numbness Altered vision Altered hearing Movement - CBR Tremors Paralysis Weakness Unsteady gait Muscle Tone and Strength WNL Flaccid Spasti c Tremors Strength Muscle Strength: 5= Within Normal Limit 4= 75% normal; 3= 50%; 2=25%; and 1=Paralysis Neck 3 RUE 3 LUE 3 RLE 3 LLE Breathing pattern – Rhythmic Apnea Bradypnea Tachypnea Shallow Eye Opening to 4 Spontaneous 3 Verbal Command 2 Pain 1 No response Verbal Response to 5 Oriented, converses 4 Disoriented, converses 3 Use inappropriate words 2 Incomprehensible sounds 1 No response Motor Response to 6 Verbal Command 5 Localized pain 4 Flexes and withdraws 3 Decorticate (Flexes abnormally) 2 Decerebrate (Extends abnormally) 1 no response
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Respiratory Orthopnea Dyspnea at Rest Dyspnea with minimal effort Dyspnea with moderate exertion Use of accessory muscle Adventitious Breath Sounds - Wheezes Right Left Crackles Right Left Diminished Right Left Absent Right Left Cough and Sputum - None Non-Productive Productive Whitish Yellowish Brownish Bloody Thick Frothy Oxygen – On room air -------- liters Nasal Cannula -------- liters Face mask Mechanical ventilator Tracheostomy Others: --------------------------------------- Cardiovascular Cardiac Parameters – Normal S1S2/Peripheral Vascular Parameters-Necrotic Extrimities Irregular pulse Palpitations Chest pain Murmurs Cyanosis Jugular Venous Distension Delayed Capillary Refill Pacemaker Pulses - Diminished Radial Right Left Popliteal Right Left Femoral Right Left
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Christopher Reinemann
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