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PATIENTASSESSMENTAge: 83-years-old Gender:FemaleResuscitation Status:Full Code Allergies:Penicillin, Sulfa Reason for Admission:Dementia; diabetes mellitus type II; severe muscle ataxia; fall riskMedical Diagnoses:Hypertension, dementia; osteoarthritis, knees bilaterally; major depressive disorder; diabetes mellitus type II; severe muscle ataxia; pancreatic disease; dyslipidemia; urinary incontinence; bowel incontinence; diarrhea; gastroesophageal reflux disease; hypomagnesemia; dysphagia; anemiaSurgeries/Procedures and Dates:Esophagogastroduodenoscopy (date of procedure not charted) Past medical history:Hypertension, dementia; osteoarthritis, knees bilaterally; major depressive disorder; diabetes mellitus type II; severe muscle ataxia; pancreatic disease; dyslipidemia; urinary incontinence; bowel incontinence; gastroesophageal reflux disease; hypomagnesemia; gastrointestinal bleed; hypoglycemia; clostridium difficile colitis; dysphagia; anemia Current Orders: Patient eats meals in the dining room breakfast, lunch, and dinner. Diet:Soft Mechanical Diet, Thickened Nectar Liquids Activity:Non-ambulatory; wheelchair bound with one assist transfer from bed to wheel chair, bedside commode, and toilet use.Intake:Not assessed Output:Not assessed Accu-Cheks:Three times a day, prior to meals. 8:00am, 12:00pm, 5:30pm Vital signs:No current vital sign orders were notated in the chart. Vital signs taken by nursing student during clinical. Temperature: 98.4; Pulse: 68, Radial; Respirations: 14; SpO2: 98%; Blood Pressure: 112/68; Height: documentation unfounded; Weight: documentation unfounded; Apical Heart Rate: 68Where is it?? Vital signs taken by nursing student?? Please provide vital signs here Dressing changes/wound care:Patient has a right thumb skin tear. Cleanse tear with non-sterile saline, pat dry. Apply xeroform and cover with dry dressing daily. Foley: Not ordered NG/G-tube/PEG/PEJ: Not ordered IV:Not ordered Other orders:Patient is a fall risk.Bed-side rails raised while patient is in bed due to fall risk. Patient requires gait belt with 1+ assist to transfer. Patient must have access to call light prior to staff leaving the room. 1STUDENT: Iva Lira Date of Care: 03/08/19
No liquids to be left in patient’s room. Most recent ImagingFindings:(CXR? CT? MRI?) No imaging results in chart.Most Recent Significant /RecentLabResults:Chemistry? Hematology? Drug Levels? Coagulation tests?)DateLab TestResultsNormsComments2/13/19White Blood Cells (WBC)9.014.8-10.8Within normal limits. WBC’sare checked for leukocytosis (white blood cell count is elevated) which may be a result of infection, stress, necrosis, neoplasia, or inflammation. In addition, this lab test is also performedto monitor for leukopenia (white blood cell count is decreased) which indicates bone marrow failure.