Urinary System: Sensory Systems: Incontinent of urine Wears reading glasses but does not require prescription lenses Wears a large brief Must speak loud to be heard but client No bladder distension noted does not wear a hearing aid Is often incontinent throughout the Has hemiparesis on right side due to night CVA No history of UTI’s Unable to verbally communicate more than or but often opts to “yes” “no” nod or shake his head when asked yes or no questions Nervous System: Integumentary System: Diagnosed with Parkinson’s Disease History of pressure ulcers on buttocks and left heel Expressive aphasia following CVA Perineum is often moist due to bladder Dysphagia should be NPO status – incontinence causing redness in the GCS of 11 area Unable to determine orientation Skin is pale and moist, no dry skin Pupils are approximately 2mm, equal noted and reactive to light Skin is warm to touch Tremors in both hands bilaterally Sunspots and moles on head and face Denies pain Outer third of eyebrows are very thin Sleeps well through the night as a result of hypothyroidism Limited facial expressions but smiles Scant amount of body hair on limbs often Hair on head is grey and thin Tympanic temperature 36.8 degrees Nails are cut short Celsius Has no current pressure ulcers or skin tears/abrasions No bruising noted
Urinary System: Incontinent of urine Wears a large brief No bladder distension noted Is often incontinent throughout the night No history of UTI’s Sensory Systems: Wears reading glasses but does not require prescription lenses Must speak loud to be heard but client does not wear a hearing aid Has hemiparesis on right side due to CVA Unable to verbally communicate more than “yes” or “no” but often opts to nod or shake his head when asked yes or no questions Nervous System: Diagnosed with Parkinson’s Disease Expressive aphasia following CVA Dysphagia – should be NPO status GCS of 11 Unable to determine orientation Pupils are approximately 2mm, equal and reactive to light Tremors in both hands bilaterally Denies pain Sleeps well through the night Limited facial expressions but smiles often Tympanic temperature 36.8 degrees Celsius Integumentary System: History of pressure ulcers on buttocks and left heel Perineum is often moist due to bladder incontinence causing redness in the area Skin is pale and moist, no dry skin noted Skin is warm to touch Sunspots and moles on head and face Outer third of eyebrows are very thin as a result of hypothyroidism Scant amount of body hair on limbs Hair on head is grey and thin Nails are cut short Has no current pressure ulcers or skin tears/abrasions No bruising noted