Semester 1 last care plan
Students Name: Laura Berrios, Lishana Casale, Kara Lanoue Date: 12/12/2014
Client’s Initials: E.P. DOB: 4/26/1937 Admission Date: 11/13/2014 from 4th Floor Religion: Jehovah's Witness Allergies: NKA Advanced Directives: Healthcare Proxy, DNR
Age: 77 Sex: Female Race: Hispanic Diet: PEG Feeding Activity: As tolerated with assistance Precautions: Fall, aspiration, skin
Admitting Diagnosis/Chief Complaint: Dysphagia
Past/Present surgical procedures: PEG placement on 11/11/14
Hx. of Present Illness: Patient is nonverbal and history of present illness is not included in the charts. Patient is a 77 year old woman who was admitted to West Gables Rehabilitation Center due to severe disability due to a recent hospitalization for psychosis secondary to dehydration and poor oral intake, PEG tube was placed on 11/11/14.
Meds .prior to admission:
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2.
3.
4.
DISEASE COMPARISON BETWEEN TEXTBOOK PICTURE AND YOUR CLIENT’S PICTURE
(This must include definition, etiology, predisposing factors, incidence, pathophysiology, signs and symptoms, diagnostic tests, and medical treatments) TEXTBOOK PICTURE CLIENT PICTURE
Disease: Osteoporosis
Definition: Degenerative disease of the bone characterized by reduced mass, deterioration of matrix, and diminished architectural strength.
Etiology: Aging causes bone loss in
Client’s Initials: E.P. DOB: 4/26/1937 Admission Date: 11/13/2014 from 4th Floor Religion: Jehovah's Witness Allergies: NKA Advanced Directives: Healthcare Proxy, DNR
Age: 77 Sex: Female Race: Hispanic Diet: PEG Feeding Activity: As tolerated with assistance Precautions: Fall, aspiration, skin
Admitting Diagnosis/Chief Complaint: Dysphagia
Past/Present surgical procedures: PEG placement on 11/11/14
Hx. of Present Illness: Patient is nonverbal and history of present illness is not included in the charts. Patient is a 77 year old woman who was admitted to West Gables Rehabilitation Center due to severe disability due to a recent hospitalization for psychosis secondary to dehydration and poor oral intake, PEG tube was placed on 11/11/14.
Meds .prior to admission:
1.
2.
3.
4.
DISEASE COMPARISON BETWEEN TEXTBOOK PICTURE AND YOUR CLIENT’S PICTURE
(This must include definition, etiology, predisposing factors, incidence, pathophysiology, signs and symptoms, diagnostic tests, and medical treatments) TEXTBOOK PICTURE CLIENT PICTURE
Disease: Osteoporosis
Definition: Degenerative disease of the bone characterized by reduced mass, deterioration of matrix, and diminished architectural strength.
Etiology: Aging causes bone loss in