Expressive Apashia Pt, lots of blanks to fill in

[mkcrturner]

Hi, I have one last care plan to do before graduation and have run into a NEW writers block.

We did our rotation in LTC facility and I learned the term "poor historian" when filling in blanks for pt's with cognitive impairment.

What I did not learn is how to fill in blanks for my stroke pt who has expressive aphasia, she cannot even blink/nod etc to express anything.

Soo does anyone have any tips for how to fill in the blanks for questions like "age at menopause," "age at menarche," "pt's expectations for this hospitalization," seatbelt use," etc.

I'm feeling a little redundant and uncreative.

TIA~Kelly

[Daytonite, BSN, RN]

This information is obtained from the chart or picking up the phone and talking to a relative.

[mkcrturner]

Thanks for the reply Daytonite. I got all the info from the chart (scant as it was)that I could and we are not allowed to make calls to family members.

This pt has been in LTC for about 2 years so the chart does not contain info like "date of last pap smear."

This care plan format is written geared toward a patient in a hospital setting, not a LTC patient, so most of the questions we need answered are not geared toward the pt's residing in LTC.

For a question like "pt's expectations for this hospitalization" or "ways you deal with stress" I was seeking something to fill in that simply/professionally states that they cannot tell me- without repeating over and over thru each section "expressive aphasia" since that would be written in about 80 out of 100 boxes :)

Or if you were coming in behind me and reading this material is "expressive aphasia" appropriate?

[Daytonite, BSN, RN]

Just say "unable to obtain information" or "information unavailable". I've also seen people write "N/A" for non-applicable or not available.

[mkcrturner]

Thanks Daytonite!! I just reread my post above your last reply- can you see how i am getting myself tied up? LOL

as simple as it was you gave me some more ways to say the same thing- and each section now has it worded slightly different.

This is our last care plan, we have a NEW instructor, was given the wrong form to fill out...so I was freaking over turning in a bare bone plan.

I spent today working on a P.O.C. page to staple to this crazy form. It is more specific to the needs of my patient- and omg I was able to add interventions about her PEG tube and include the fact that I dont want her to asphyxiate. hehehe

So although I have no idea when she had first menarche..... I do know a few interventions :)

Thanks again