members. NUTRITIONAL/ Patient states During shift pt. Regular diet Patient seems to that she will eat ate 75% of (chart) METABOLIC have adequate Patterns of food and between 75-100 dinner. nutritional intake fluid consumption, percent of her Skin turgor for dietary needs, Weight, skin turgor. meals, was less than but may need (Skin, Hair, Nails; depending on three seconds, additional protein Head & Neck; what is offered. and no tenting and Mouth, Nose, Sinus; Patient states present. carbohydrates for swallowing, Ht., Wt) that she drinks Skin was dry wound healing. all of the and warm with beverages good color. offered with the Oral cavity was meals, as well as moist and pink. a cup of coffee DH stated that in the morning she wore and water dentures. throughout the day. DD is 62 inches tall, 108 lbs. DD is partially able to perform own self care. Patient is given polyethylene glycol once a day. Patient is given docusate sodium once a day. Patient may have ELIMINATION Patient states Abdomen soft “I elimination have no pain or symmetrical Patterns of excretory problems related urgency when I and function & to opioid need to go to the Elimination of waste; analgesic therapy bathroom”. Bowel sounds relevant labs, PRN. present in all Medications, four quadrants. Patient states, impacting, etc. last bowel Pt. denies pain “My
members. NUTRITIONAL/ METABOLIC Patterns of food and fluid consumption, Weight, skin turgor. (Skin, Hair, Nails; Head & Neck; Mouth, Nose, Sinus; swallowing, Ht., Wt) Patient states that she will eat between 75-100 percent of her meals, depending on what is offered. Patient states that she drinks all of the beverages offered with the meals, as well as a cup of coffee in the morning and water throughout the day. During shift pt. ate 75% of dinner. Skin turgor was less than three seconds, and no tenting present. Skin was dry and warm with good color. Oral cavity was moist and pink. DH stated that she wore dentures. DD is 62 inches tall, 108 lbs. DD is partially able to perform own self care. Patient is given polyethylene glycol once a day. Patient is given docusate sodium once a day. Regular diet (chart) Patient seems to have adequate nutritional intake for dietary needs, but may need additional protein and carbohydrates for wound healing. ELIMINATION Patterns of excretory function & Elimination of waste; relevant labs, Medications, impacting, etc. Patient states “I have no pain or urgency when I need to go to the bathroom”. Patient states, “My last bowel Abdomen soft symmetrical and Bowel sounds present in all four quadrants. Pt. denies pain Patient may have elimination problems related to opioid analgesic therapy PRN.
Bradley%20Gerontology%20Process%20Paper%20(Repaired).docx