V.

ASSESSMENT TOOL Days of Assessment: o Week 1 Assessment Day- February 5, 2013 o Week 1 Day 1- February 6, 2013 o Week 1 Day 2-February 7, 2013 I. GENERAL INFORMATION Name: Patient CKC Birthday: July 7, 1934 Sex: Male Age: 78 years old Civil Status: Married Religion: Roman Catholic

Occupation: Retired CPA Address: Caballero Compound, Adela Subdivision, Camaman-an, CDO Informant: Patient CKCs wife Admission Date: September 21, 2012 Attending Physician: Dr. A Chief Complaint: Fever Final Diagnosis/ Impression: Sacral Decubitus Ulcer Grade IV, Anemia S/P Blood Transfusion, Hypertensive Cardiovascular Disease, Coronary Artery Disease 3-Vessel, Dyslipidemia, S/P Cerebrovascular Disease with Residual Hemiparesis History of Present Illness: Time: 6:27 PM

Vital Signs: Heart Rate Respiratory Rate Week 1 Assessment Day Week 1 Day 1 64 bpm 20 cpm 36.0C Temperature Blood Pressure 90/60mmHg Oxygen Saturation -

Weight: not assessed BMI:

Height: 511

II. ACTIVITY/REST Subjective Week 1 Usual Activities/ Hobbies Leisure Time Activities Limitations Imposed By Condition Number of Hours of Sleep permi man siya tulog. Week 2

Wala man, 2 years na siya bedridden. Tanaw TV, maglaag. Usual activities are halted.

Naps Aids Difficulty in Sleeping Feeling on Awakening

permi man siya tulog. None None "Ayha ra kung limpyohan namo iyang samad ug mag-oral care.

Other Comments

None

Objective Observed response to activity: patient is bedridden Cardiovascular: 64 bpm/ Respiratory: 20cpm/ Mental Status: lethargic 4 Tremors: present Posture: slouched LOM: Level

Others/Comments: Patient has Parkinsons Disease according to his wife

III. CIRCULATION Subjective History of hypertension: Naa man pero dili na nako ma-trace kanus-a gyud nagsugod. Heart trouble: Naa pud, na-stroke gani ni siya sa una. Ankle/Leg edema: none Slow healing: no none Claudication: Paralyzed man siya. Cough/Hemophysis:

Extremities Numbness and Tingling: Ang right side. Change in frequency/amount of urine: naka-diaper man siya. Others/Comments: Patient has right hemiparesis

Objective BP (R) Lying: 90/60mmHg Sitting: not assessed; patient is bedridden

Standing: not assessed; patient is bedridden (L) Lying: not assessed due to IV line Sitting: not assessed; bedridden Standing: not assessed; patient is bedridden Pulse Pressure: 30 mmHg PMI: apical Heart rate/ Sounds: 64 bpm; S1 (lub) and S2 (dub) heard over right of midclavicular line Rhythm: Regular heart rhythm Breath sounds: bronchovesicular Extremities: Temp: 36.0C Capillary refill: <3sec Vascular bruit: None Jugular vein distension: None Color: pinkish Homans sign: Negative patient is

IV.EGO INTEGRITY Subjective Week 1 Reports of Stress Factors Ways of Handling Stress Financial Concerns Relationship Status Lifestyle Sturya-sturyahon lang nako siya. None Okay ra man Kaon, tanaw TV, tulog. Ang iyang condition karon Week 2

Sedentary gyud na siya ug lifestyle. Recent Changes Feelings of Helplessness Hopelessness Powerlessness Other comments Patient has a good support system from his wife Dili na siya makalaag. Cannot be assessed since patient is has slurred speech.

Objective Emotional Status (Check those that apply) Calm Withdrawn Anxious Fearful Angry Irritable Euphoric

Observed physiologic response: Patient is lethargic. Others/comments: Data are taken from his wife.

V. ELIMINATION Subjective Week 1 Usual Bowel Pattern Twice or thrice a week Week 2

Character of Stool

medyo basa-basa nga tibugol

Last BM Laxative Use History of Bleeding Hemorrhoids Constipation Diarrhea Usual Voiding Pattern

ganina morning 2-13-14 None None None None None dili ko kabalo ra ba, nakadiapers man gud siya.

Incontinence Urgency Retention Frequency Pain/Burning/Difficulty in Voiding History of Kidney/ Bladder Disease Other comments Abdomen: Tender: Not tender Size/Girth: not assessed Bladder palpable: Not palpable Soft/Firm: not assessed

None None None None None

None

Wife stated that patient has urinary retention.

Palpable Mass: None

Bowel sounds: normal bowel sounds Distended: Not distended

VI. FOOD/FLUID Subjective Week 1 Usual diet (type): Week 2

American diet: burger, fries, chicken, beef, meat, mga inana.

# of Meals/Day Last Meal/intake

4x/day with snack November 28, 2012 (rice with viand)

Loss of Appetite

I dont know. Ga-feeding na lang man siya.

Nausea/Vomiting Dentures Allergies/Food Intolerance Heartburn/Indigestion Swallowing Problems Weight: Usual

None naa pero gitanggal na. None None None

wala ko kabalo basta kay dako na siya sa una. Murag si Santa Claus.

Changes Diuretic Use

niniwang siya ug maayo. None

Other comments

Wife does not know the normal body weight of the patient

Objective Current weight: not assessed Skin turgor: 5 sec, poor Hernia/masses: None Edema: General: None Periorbital: None Thyroid enlarged: None Dependent: None Ascites: None Ht: 511 ft Body build: mesomorph

Mucous membrane: dry and with canker sore

Halitosis: None

Conditions of teeth/gums: incomplete set of teeth w/ cavities, dentures and canker sore Appearance of tongue: Pinkish with no lesions Others/comments: Patient has dry lips and is fed via NGT.

VII. HYGIENE Subjective ADL (Independent/ Dependent) Mobility D/I Feeding D/I Dressing D/I Other: none Toileting D/I Hygiene D/I

Equipment/ presence of devices required: NGT Assistance provided by: wife Others/comments: Patient is dependent in all activities

Objective Week 1 General Appearance Patient has generalized weakness; pressure sore noted Manner of Dress Habits Body Odor Condition of Scalp Presence of Vermin Other comments Patient is dressed with hospital gown None in particular No body odor Clean and intact None Patient is clean and taken care of by wife and/or nurse Week 2

VIII. NEUROSENSORY Subjective

Week 1 Fainting Spells/ Dizziness Headache Location Frequency Tingling/ Numbness/ Weakness Location Seizures Aura How Controlled if hilantanon siya None Not applicable Not applicable Right side weakness None

Week 2

wala ko kabalo ra ba. Use of anti-seizure medications; Leviteracetam 1gm 1tab BID

Eyes: Vision Loss Right Eye Left Eye Last Eye Examination Glaucoma Cataract Sense of Smell Epistaxis Other comments None None None 2 years ago man siguro to None None okay ra man None Data are taken patients wife

Objective Mental status: _ Alert _Comatose Affect: Flat Memory: Recent: not assessed Remote: not assessed Speech pattern: slurred Time: not oriented Place: not oriented Person: Oriented _Drowsy _ Cooperative Lethargic _Combative Hallucination: none _Stuporous

Delusions: None

Congruence: not congruent Glasses: None Pupil size/reaction: Facial droop: None Handgrip/release Contact: None (R) PERRLA Hearing aids: None (L) PERRLA

Swallowing: patient is on NGT (R) & (L): weak Paralysis: Right side

Posturing: Slouched DTR: not assessed

Others/Comments: Patient is lethargic, has general weakness, right hemiparesis

IX. PAIN/COMFORT Pain cannot be assessed due to patients current state. Objective Patient is lying down during the day and is moaning. Other Comment: Pain cannot be assessed since the wife is the one giving information.

X.RESPIRATION Subjective Dyspnea related to: None Cough/sputum: none History of _Bronchitis _Asthma _Emphysema _Recurrent Pneumonia Smoker: no Packs: N/A Brand: N/A Use of respiratory aids: none _TB _Exposure to noxious fumes

# of years: N/A Oxygen: None

Others/Comments: Patient has no problems regarding respiration.

Objective Week 1 Assessment Day Respiratory Rate Depth Symmetry Use of accessory muscles Deep Symmetrical None 20 cpm Week 1 Day 1 Week 2 Assessment Day Week 2 Day 1 Week 2 Day 2

Nasal Flaring Fremitus Breath Sounds Cyanosis Clubbing of Fingers Sputum Characteristics Restlessness Other comments

None Not assessed Bronchovesicular None None

none

None No abnormalities noted

XI.SAFETY Allergies/Sensitivity: none Reaction: N/A History of STD (Date/Type): none Blood Transfusion/ Number: 8 bags When: September, October and ganina. History of Accidental Injuries: sa una, na-aksidente ni siya. Nabanggaan ug van.

Fractures/dislocations: herniated disk Arthritis/Unstable joints: none Back Problems: iyang sore Changes in Moles: none Enlarged Nodes: none Prosthesis: none Ambulatory Devices: none Expression of ideation of violence (self/others): not assessed Other comments: Patient had a vehicular accident before. Objective Week 1 Assessment Day Temperature Diaphoresis Skin Integrity Scars Rashes Lacerations 36.0C None Impaired; with pressure sores at the back and sacral area. None None None Week 1 Day 1 Week 2 Assessment Day Week 2 Day 1 Week 2 Day 2

Ulcerations Ecchymosis Blisters Burns (degree %) Drainage (Note Location) General Strength

None None None None

None

Patient appears weak

Muscle Tone Gait Paresthesia/ paralysis Other comments

Poor Slouched Right hemiparesis

Patient is at risk for infection

XII.SEXUALITY Sexually active: no Sexual concerns/difficulties: not assessed

Recent change in frequency/interest: not assessed

Female Age of Menarche: N/A Length of Cycle: N/A Last Menstrual Period: N/A Menopause: N/A Vaginal Discharge: N/A Bleeding between periods: N/A Pregnancy History: N/A G T P A L M

Episiotomy: N/A Lochia: N/A Complications of Pregnancy: N/A Surgeries: N/A Hormonal therapy/ calcium use: N/A Practice SBE: N/A

Discharges: N/A Last PAP Smear: N/A Method of birth control: N/A Other comments: Patient is male

Objective Breast Examination: N/A Vaginal Warts/Lesions: N/A Other comments: Patient is male Subbjective Penile discharge: None Circumsized: oo Prostate Disorder: Benign Prostatic Hyperplasia Vasectomy: wala

Practice SBE/testicles: wala ko kabalo Last proctoscopic/prostate examination : kalimot ko Others/Comments: Patient has benign prostatic hyperplasia

XIII.SOCIAL INTERACTIONS

Marital Status: married Years in Relationship: 8 years Living with: wife and niece Concerns/stresses: present condition Extended Family: living with niece Other support person: none Role within Family Structure: husband Report of problems related to illness/condition: not assessed Other comments: Patient has strong support system

TEACHING/LEARNING Dominant Language (specify): English Literate: Oo Educational Level: nag-graduate jud siya. CPA siya. Health Beliefs/practices: paycheck-up sa doctor

Risk Factors

(Check all that apply)

Relationship

Diabetes Tuberculosis Heart Disease Stroke High BP Epilepsy Kidney Disease Cancer Mental Illness

Wala ko kabalo

Use of alcohol (amount/frequency): no Other comments: Patients wife doesnt know the history of patient.

Dry mouth noted; accumulation of secretion noted, cant be expectorated and needs to be suctioned

With NGT

Hemiplegia right

Decerebrate; dry skin noted

Development of a sore due to skin fold

With bed sores; dressing with bloody secretion and undergone debridement

*Generalized weakness and loose skin noted.