my paper on my patient...can someone help me with it?

  1. Mr. P. is receiving the following medications:

    1. ASA 81mg peg qd
    2. Artificial tears 1 drop per eye prn
    3. Ambien 5mg prn hs
    4. Colace 100mg liquid peg qd
    5. Detrol 2mg peg bid prn
    6. Lovenox 40mg sq qd
    7. Lopressor 25mg peg bid
    8. Plavix 75mg peg qd
    9. Pobalance 7x a day per peg
    10. Milk of Magnesia 30ml peg prn for constipation
    11. Tylenol 650mg peg prn

    He had a CVA. I am going to concentrate on his left sided weakness. What 3 meds would be top priority for my patient?


    AND


    Is this a good assessment?
    Mr. P was admitted to Heartland of Mentor on because I discovered from documentation in the chart that he was there for therapy due to a recent CVA. He was transferred from Hillcrest hospital on 9/30/2005.

    0800 Thin male patient supine in bed, eyes open, watching television.

    Vital signs Temp: 95.9F , Pulse 77 apical regular, Resp 22 even, unlabored, BP 122/65, pulse ox 97%

    Neuro a&o x 3. PERRLA. Obeys simple commands. Smiles when greeted.

    Cardiovascular Apical regular 77. Radial pulses +2 . Pedal pulses +2.

    Respiratory Breath sounds in anterior and posterior lobes clear bilaterally. Chest rise symmetrical, DOE. Rate 22. Cough absent. Mucous membranes moist and pink.

    GI Normoactive bowel sounds x4 quadrants. Abdomen soft. Peg tube patent. Placement checked. Dressing changed. Scant amount of yellow drainage noted. Dressing dry and intact Ambulatory with aid of 2 transfers to w/c to bathroom & continent of soft formed brown stool.

    GU Incontinent in diaper of clear yellow urine.

    Integument Skin warm, dry, smooth, no inflammation.

    MS Peripheral extremities warm, no edema. Bilateral peripheral extremities cap refill <3 sec & brisk. Foot pedals and hand grasps equal and strong. Pt able to do active ROM on all extremities. Patient needs assistance x2 with mobility. Weakness to the left side. Gait unstable.

    Pain No c/o pain.

    Psychosocial Pt easy to work with. He seems unhappy by stating, "I am just sad because I can't do everything I used to be able to do."

    1030 Pt leaves via w/c to physical therapy with therapist.
    •  
  2. 4 Comments

  3. by   lpn1313
    Is this a good assessment?
    Mr. P was admitted to Heartland of Mentor on because I discovered from documentation in the chart that he was there for therapy due to a recent CVA. He was transferred from Hillcrest hospital on 9/30/2005.
    ---Not sure, but I don't think you need the ' because I discovered... that he was there' line. Go right from admitted to HoM for therapy for CVA from HH
    0800 Thin male patient supine in bed, eyes open, watching television.
    ---If you're writing that he's watching tv- stating his eyes are open isn't necessary
    Vital signs Temp: 95.9F , Pulse 77 apical regular, Resp 22 even, unlabored, BP 122/65, pulse ox 97%

    Neuro a&o x 3. PERRLA. Obeys simple commands. Smiles when greeted.

    Cardiovascular Apical regular 77. Radial pulses +2 . Pedal pulses +2.

    Respiratory Breath sounds in anterior and posterior lobes clear bilaterally. Chest rise symmetrical, DOE. Rate 22. Cough absent. Mucous membranes moist and pink.
    ---anterior and posterior lobes? Lobes are not front and back
    GI Normoactive bowel sounds x4 quadrants. Abdomen soft. Peg tube patent. Placement checked. Dressing changed. Scant amount of yellow drainage noted. Dressing dry and intact Ambulatory with aid of 2 transfers to w/c to bathroom & continent of soft formed brown stool.
    ---If the dressing was changed, it's then assumed to be dry and intact. Ambulatory statement and transfer status should be in MS not here.
    GU Incontinent in diaper of clear yellow urine.
    ---adults wear briefs, not diapers
    Integument Skin warm, dry, smooth, no inflammation.

    MS Peripheral extremities warm, no edema. Bilateral peripheral extremities cap refill <3 sec & brisk. Foot pedals and hand grasps equal and strong. Pt able to do active ROM on all extremities. Patient needs assistance x2 with mobility. Weakness to the left side. Gait unstable.
    ---Foot pedals, hand grasps equal and strong...weakness to left side?
    Pain No c/o pain.

    Psychosocial Pt easy to work with. He seems unhappy by stating, "I am just sad because I can't do everything I used to be able to do."
    ---compliant with requests. No need to say "seems unhappy" just write statement
    1030 Pt leaves via w/c to physical therapy with therapist.[/QUOTE]

    As far as the list-anticoagulants, antihypertensives, peg feedings. Keep in mind that I haven't had to summarize anything for your instructor. He/She may want different things. You have all the basic info, it just needs to be organized better, and that comes with time. And lots and lots of practice.
  4. by   msmona
    Thanks for asking that question. I have my LTC clinical tomorrow and will keep all this in mind.
    MsMona
  5. by   Janinern84
    Thanks so much!! I used your ideas to make my paper better
    I appreciate it. I hope i get the points i need!!
    ~Janine
  6. by   stn2003
    If the main hx regarding the pt is neuro (CVA), you might want to include a more complete neuro assessment, like: presence of any facial droop? hand grasps strong and equal bilat? dorsal/plantar flexion strong bilat? Is speech clear or garbled? Does he respond to questions appropriately? etc.

close