(Abdominal - and movement was with bladder) on 2/5/12”. palpitation. Patient is given 17gm of polyethylene glycol once per day. Patient is given 240 mg of docusate sodium once per day. Patient may take 500mg of hydrocodone q 6h as needed for pain. Patient’s Braden DH denies any Heart sounds Patient is up with score indicates a shortness of were regular. assist (chart). risk for Patterns of exercise & breath or Lung sounds Patient is developing a daily living, presence of were encouraged to pressure ulcer. self-care activities cough. Patient was change position include DH states that breathing at 16 in bed q 2 Patient is body systems she tries to do as respirations per (chart). cooperative and involved. much as she can minute. DH had an willing to try to (Thoracic & Lung; on her own, but assessment for Katz ADL perform self-care Cardiac; needs assistance PT ordered score was 3 out activities unless Peripheral vascular; when she (chart). There of 6. becomes too tired Musculoskeletal, becomes tired were no results to do so. vital signs) Patient had a during self-care indicated in her Braden score activities. chart. Due to lack of of 18/23. DH states that mobility, patient Patient had a she enjoys is at a greater risk Fall Risk score participating in of developing of 6. activities during infection or DVT. Patient is the day but taking enjoys her Cordarone 200 private time as mg daily. well. Patient is taking levothyroxine
(Abdominal - and bladder) movement was on 2/5/12”. with palpitation. Patient is given 17gm of polyethylene glycol once per day. Patient is given 240 mg of docusate sodium once per day. Patient may take 500mg of hydrocodone q 6h as needed for pain. Patterns of exercise & daily living, self-care activities include body systems involved. (Thoracic & Lung; Cardiac; Peripheral vascular; Musculoskeletal, vital signs) DH denies any shortness of breath or presence of cough. DH states that she tries to do as much as she can on her own, but needs assistance when she becomes tired during self-care activities. DH states that she enjoys participating in activities during the day but enjoys her private time as well. Heart sounds were regular. Lung sounds were Patient was breathing at 16 respirations per minute. Katz ADL score was 3 out of 6. Patient had a Braden score of 18/23. Patient had a Fall Risk score of 6. Patient is taking Cordarone 200 mg daily. Patient is taking levothyroxine Patient is up with assist (chart). Patient is encouraged to change position in bed q 2 (chart). DH had an assessment for PT ordered (chart). There were no results indicated in her chart. Patient’s Braden score indicates a risk for developing a pressure ulcer. Patient is cooperative and willing to try to perform self-care activities unless becomes too tired to do so. Due to lack of mobility, patient is at a greater risk of developing infection or DVT.
Bradley%20Gerontology%20Process%20Paper%20(Repaired).docx