Table of Contents Patient and Medical Record InformationChronological Development of Clients Number One Medical DiagnosisCurrent Signs and SymptomsTextbook InformationCompare and ContrastMedical History and Health EvaluationSystems ReviewHead and NeckChestAbdomenReproductive SystemPost MenopauseNeurologicalCranial Nerves: IntegumentaryEndocrineAllergiesMedical and surgical historySocial habitsFamily/family composition ly Health ProblemsDiet therapyPhysical and cognitive abilityNursing diagnosis/Problems/NeedsShort-term goalLong-term goalInterventionsE.S. is a 94 year old woman, born July 30, 1909. She is a widow. She is Catholic. He stated that his mother was German and his father was Irish. She is an only child and never finished school because she married at a young age. His admission date was July 8, 2002 with the diagnosis of left hip fracture and dementia. She was admitted to the hospital for a fractured left hip on July 2, 2002 and then transferred to the nursing facility due to the client's inability to care for herself, as evidenced by her inability to remember whether she took her medications and her need for assistance when using the bathroom. Its code status is DNR, comfort measures only. Antibiotics for infections are fine, but no feeding tubes or intravenous fluids. He has a complete upper and partial lower denture. She receives a bed bath and gets her nails and hair done once a week. He uses a wheelchair to ambulate, requires assistance getting out of the wheelchair to stand, and is unable to walk. The level of activities is limited to those that can be performed in a wheelchair. He needs assistance using the bathroom and help transferring to and from the wheelchair. Say no to plagiarism. Get a tailor-made essay on "Why Violent Video Games Shouldn't Be Banned"? Get an Original Essay About Patients and ChartsChronological Development of Clients Number One Medical Diagnosis The primary medical diagnosis of ES is dementia. His hip fracture may have been caused by changes in muscle coordination/balance, which is a symptom of dementia (Doenges, Moorhouse, & Geissler, 2002). He now uses a wheelchair for walking and requires assistance moving to and from the wheelchair. Her hip fracture has now healed, but she is still unable to care for herself due to declining cognitive abilities. Current Signs and Symptoms Current signs and symptoms of the client's primary diagnosis of dementia include forgetfulness, inability to determine whether or not a task has been done, as evidenced by not being able to remember whether she brushed her teeth or took her medications. Inability to remember factual information or recent/past events, as evidenced by inability to orient oneself to the residence, or if the child had returned from vacation. She expressed fear of further mental/physical deterioration by stating that she can't bear the thought of "not being able to do anything but lay there and depend on everyone to take care of me, and she can't talk." She has been diagnosed with depression which is often associated with dementia (from the table). She tries to remember the names of the people in her photographs and then becomes frustrated, as evidenced by the customer stating, “I'm going to put it away and never look at it again.” He is unable to orient himself in time (he does not know the season or what year it is). The client has ankle edema related to her immobility. He is also underweight and has difficulty swallowing. Textbook InformationDementia is a general term for a permanent or progressive organic mental disorder characterized by personality changes,confusion, disorientation, deterioration of intellectual functioning, and impaired control of memory, judgment, and impulses. The most common type of dementia is Alzheimer's disease (AD). Its cause is unknown. The most prominent symptoms are cognitive dysfunction, including declines in memory, learning, attention, judgment, orientation, and language skills. The symptoms are progressive and all victims experience a steady decline in cognitive and physical abilities, lasting 7 to 15 years and ending in death. In the last stage, the client requires total assistance, is unable to communicate, is incontinent and may not be able to walk. There is no cure (Kozier, Erb, Berman, & Burke, p. 422). Dementia can result from many diseases, including AIDS, chronic alcoholism, Alzheimer's disease, vitamin B12 deficiency, carbon monoxide poisoning, cerebral anoxia, hypothyroidism, hematoma subdural, multiple cerebral infarctions and others. Limited benefit is obtained in some patients treated with donepezil, tacrine or gingko biloba (Venes, 2001). New studies suggest that hormone replacement therapy (HRT) may reduce the risk or delay the onset of Alzheimer's disease (AD), which is the most common form of dementia among older adults. Growing evidence supports a role for estrogen in brain regions involved in learning and memory and in the protection and regulation of cholinergic neurons, which degenerate in AD (Fillit, H., September 23, 2002). Compare and ContrastClient clearly shows signs of confusion, disorientation, deterioration of intellectual functioning evidenced by inability to orient oneself in place and time. She has difficulty remembering concrete information, such as whether she brushed her teeth that morning or whether or not she has already been given medicine. However, he is able to perform daily tasks such as combing his hair and brushing his teeth when reminded. He shows no signs of aggressive behavior or suspiciousness that are symptoms of dementia. She is able to remember things that were very important to her, such as stories about her children and her husband. Expresses interest in being with others and participating in group activities showing a desire not to be isolated from others. His disease is progressive and the prognosis is poor. His cognitive and physical abilities will continue to decline. He will become increasingly dependent on others for ADLs until he becomes totally dependent, and will likely end in death. Review of medical history and health assessment systems Head and neck No headaches, head injuries, neck pain or dizziness. No lumps or swelling in the neck. The client has difficulty swallowing (dysphagia). He has never smoked and does not drink alcohol. The head is normocephalic. The temporomandibular joint moves easily without limitations or pain. The facial expression is appropriate for the reported mood. The facial structures are symmetrical. No involuntary movements (tics) in the facial muscles. The head position is centered on the midline and the accessory neck muscles are symmetrical. No enlargement of salivary or lymph glands. The trachea is centered on the midline. The thyroid is not palpable. Eyes. The client has glaucoma. The eyebrows show a loss of the outer half of the hairs, bilaterally. bilaterally, they move symmetrically as facial expression changes, without scaling or lesions. The skin of the eyelids is intact and pink without redness, swelling, discharge, or bilateral lesions. The eyelashes are evenly distributed along the eyelid margins and curve outwards, bilaterally. The eyeballs are aligned normally in their sockets withoutprotruding or sunken appearance bilaterally. The conjunctivae are clear, semi-moist. The sclerae are white, with a gray spot about 1 cm in diameter on the right eye. The pupils are equal, round, the size of a pin, and are not reactive to light or accommodation (client receives Isopto Carpine drops, left eye). The client was unable to undergo visual field testing (cranial nerve II), due to mental status. Extraocular muscles, absent corneal light reflex. Diagnostic testing of positions reveals an inability to follow from 12 o'clock to 2 o'clock, indicating weakness of an extraocular muscle (EOM) or dysfunction of the cranial nerve innervating it. Cranial nerves III, IV and VI (ocularmotor, trochlear, abducens) intact. Unable to test the red reflex or observe the internal structures of the eye due to constriction of the pupils. The cover test reveals a normal result with a firm and fixed gaze. The lens appears opaque. Ears. No lesions, swelling, redness present in the external auditory meatus, bilaterally. No tenderness bilaterally. Both ear canals are filled with yellow, crusted, scaly earwax, which blocks the view of the tympanic membrane. Client unable to hear whispered words (cranial nerve VIII). With both the Weber and Rinne tests, the client was unable to hear the tuning fork. The client stated that she could feel the vibrations but could not feel anything. He was able to hear the tuning fork when it was placed right next to the external auditory meatus, bilaterally. Nose. Frequent nasal discharge. The discharge is watery. The nose is symmetrical, on the midline and in proportion to the other facial features. The patency test reveals no obstructions. The nasal mucosa is normal red in color and has a smooth, moist surface, with some swelling. No polyps or benign growths. Septum not deviated. Mouth. The lips are normal red, slightly moist, without cracks or lesions. No sores, lesions, lumps in the mouth or tongue. The buccal mucosa is pink and moist without lesions. There is a small lesion in the upper anterior gum, approximately 0.25 cm in diameter, white in color. The client has painless dysphagia, feels as if food is stopping at certain points during swallowing. The client has never smoked and does not use alcohol. The client has a full upper and partial lower denture. Performs oral hygiene twice a day. The tongue does not present ulcerations with the presence of some fissures. The ventral surface appears smooth, shiny and shows veins, saliva is present. There are no lesions on the ventral surface. The tonsils are rated 1+. No unusual breath odor. The uvula does not rise when the client says “ahhh” (cranial nerve X), but hangs in the midline. The tongue protrudes along the midline with only a slight tremor (cranial nerve XII). Tonsils rated 1+. No abnormal breath odor. Lymph nodes. Not palpable. Breasts. Not painful or swollen. Respiratory chest. Thin chest wall (Graph). Occasionally congested with persistent cough, crackles in the upper part of the lungs (graph). Left lung wheeze/rattle audible during expiration, at the 4th intercostal space, posterior and midclavicular lines. No areas of tenderness or increased skin temperature. No increase in skin moisture. No superficial lumps or masses, no skin lesions. No evidence of tactile thrill. Cardiac. Regular rhythm without murmurs. Clear heart tones. Abdomen Gastrointestinal. Constipation. Anemia improving. Body mass index outside the parameters. Calorie intake does not meet estimated fluid needs (graph)Urinary strain. Wear depends. Requires assistance when using the bathroom.Reproductive system Post menopause Extremities. Arm, hand, and shoulder ROM reveal an overall decrease in ROM of approximately 10%. Venous lacustrine structures present in the hands and arms. No nail stick. The nails have a 2 second capillary refill. Feet, knees and toes reveal a decrease in ROM of approximately 30%. Pain with rotation of the left hip (graph). The feet and lower legs are purple due to reduced circulation. There is edema of the ankles, with pitting classified as 3+. The lower legs each have a 1.5 cm lesion that is white and scaly. The popliteal, posterior tibial, and dorsalis pedis pulses are weak and rated a 2+ and are regular, rhythmic, elastic, and resilient. The radial and brachial pulse is also classified as 2+, rhythmic, with elastic and resistant arteries. Pulse at 84 beats per minute. Neurological The client is alert, but not oriented to place or time. He is unable to name the people in the photographs. He doesn't know what time of year it is, or even what year it is. He often forgets how to get back to his room or what his room number is. However, he knows what city he is in and knows he is in a nursing home. No history of unusual headaches. Occasional dizziness. No tremors in hands or face. Incoordination evidenced by fall (hip fracture). No numbness or tingling. Difficulty swallowing, no pain. No difficulty speaking. No significant past history of stroke, spinal cord injury, meningitis or encephalitis, birth defects, or alcoholism. However, some history may be omitted due to customers' inability to remember actual information. This would include a history of dizziness without a specific time period (how often they occur). The client notices decreased memory and feelings of confusion. Cranial nerves: not performed. Optic nerve test not performed due to client's failure to comply. The pupils shrank even in low light conditions and did not constrict further as a result of the test. Intact. The movement of the eye downwards and inwards is observed. Intact. The muscles of mastication feel equally strong, bilaterally. Intact. Observed lateral movement of the eye. Intact. Mobility and symmetry observed with facial muscle movement with observed facial expressions. Unable to hear the whisper test, the tuning fork in the Weber test, or the tuning fork in the Rinne test until the tuning fork is placed next to the external auditory meatus, bilaterally. The uvula does not rise when the client says "ahhh". The sternomastoid and trapezius muscles are equal in size bilaterally, with equal resistance to force applied to the side of the chin. The shoulders move with equal force to the resistance. The tongue protrudes along the midline without tremor. Brain function test, Romberg test, heel-shin test not performed due to client's mobility status. The client is able to feel the pinprick and light touch. The client can feel the vibrations of the tuning fork on the bony prominences. Deep tendon reflexes not present, responses rated 0. Integumentary skin is thin. The temperature is warm bilaterally. The skin is clean and free of body odor. the hair is fine, thin, gray. The thickness of the nail is uniform. Poor skin firmness, pinched skin slowly recedes. The feet and lower legs are purple due to reduced circulation. There is edema of the ankles, with pitting classified as 3+. The lower legs each have a 1.5 cm lesion that is white and scaly. Endocrine system No history of diabetes. The thyroid is not., 2001).