Comprehensive: Assisted Living,
assess for continuing current living arrangement
Identifying information
JT is a 89 years old Caucasian female, date of birth 1-20-06. Resides at assisted living facility.
Source of information
Daughter. Client unable to give history due to aphasia.
Purpose
Comprehensive Assessment, home visit. Daughter is primary caregiver. She wanted to get feedback on managing her parent’s care in an assisted living community, hoping to be able to continue to keep them in assisted living without having to move them into a nursing home, and still be able to have their needs met.
Past Medical history
Childhood Illnesses: Unknown.
Adult illnesses/hospitalizations:
-Parkinson’s diagnosed in 1994.
-Aspiration pneumonia in Feb 1995 hospitalized.
-1986 compression fracture of spine.
-1989 left hip fracture with left hip replacement.
-1993 right hip fracture with right hip replacement.
-Left CVA post-op after right hip replacement, residual hemiparesis and aphasia.
-Cerebellar ataxia.
-History of hiatal hernia, diagnosed fall 1994.
-Esophageal dysmobility, secondary to stroke.
Allergies: Bee stings
Immunizations:
-Influenza vaccine yearly, last fall 1994.
-Pneumovaccine Feb. 1995.
-Last tetanus shot unknown.
Screening Tests:
-Dentist every 6 months.
-Ophthalmologist within past 6 months.
-Comprehensive physical 1994.
-Mammogram unknown.
Diet:
-Mechanical soft diet, good appetite. Needs assistance with eating.
-Eats a balanced diet with fruits, vegetables, small portions of meats and eggs, drinks fruit juices and water.
Current medications: Baby aspirin 1 QD
Tobacco: Never smoked.
Alcohol/Drug use: No alcohol and no illicit drug use.
Family History
-Married with one daughter.
-Daughter is primary caregiver living a few miles away.
-Mother and father dead, causes unknown.
-Four brothers, two sisters. Three brothers lived until 80+, one died in accident, sisters died unknown causes.
Psychosocial history
-JT is retired teacher.
-Adventurous woman in younger years.
-Traveled alone to Wyoming to teach, by herself.
-Enjoyed horseback riding, ice skating, writing children’s books, has strong religious faith, attends church on occasion with daughter and attends at facility.
-Currently limited by her aphasia and immobility secondary to stroke.
Psych History: No known history of depression or anxiety.
Review of systems
General: Health is fair, has had multiple health problems in last few years, which have left her with chronic disabilities. Wheelchair bound, flat affect. Verbal responses slow, only one word, yes. Appears alert and oriented to person difficult to assess cognitive status. Recognizes people.
Skin: No problem with rashes, itches, or lumps.
HEENT: No complaints of headaches, according to daughter. History of cataracts, wears prism glasses, no apparent hearing loss, no nasal congestion, upper partial plate of teeth, needs plenty of time for eating, tolerates swallowing cold foods best.
Respiratory: No shortness of breath or history of lung problems.
Cardiac: No known chest pain, no history of hypertension, no history of palpitations or heart failure.
Hematological: No easy bruising, no bleeding disorders.
Endocrine: No heat or cold intolerance, no history of thyroid problems, no excessive thirst or urination.
Breasts: No nipple discharge, no masses.
Abdomen: No nausea or vomiting, no constipation or diarrhea.
GU: Does have incontinence at night, wears diaper at bedtime.
Musculoskeletal: Up with assistance of one, pivot assist from bed to wheelchair. Had been receiving physical therapy for several weeks post-hospitalization in February with improvement in strength. Ambulates short distance with assistance pushing wheelchair.
Neurologic: No known dizziness, history of stroke.
Psychiatric: Patient has good demeanor with multiple physical limitations.
Physical Exam
General: Height 5’6”, no scale for weight slender build weight looks proportion to height and body build, well-groomed and dressed, looks young for age, BP 142/70, HR 68, R 20, T 97.8.
Skin: Warm, dry, nails normal, with good capillary refill, no rashes, sores or lesions, heels are slightly pink, skin intact, due to lying in supine position.
HEENT: Hair gray evenly distributed, scalp without tenderness, skin without masses, intact, unable to assess eye exam due to patient squeezing eyes shut, pupils even in size, sclera with without discharge, eyes and brow symmetrical. TM intact gray with good cone reflex, bony landmarks present, canals clear, patient responds to voice without apparent hearing loss. Nasal mucosa pink, without discharge or polyps, sinuses non-tender.
Mouth: Mucosa pink, intact, gums and pharynx pink without erythema, or lesions. Tongue and uvula midline. Trachea midline, no palpable thyroid nodules or enlarged thyroid. No palpable lymph nodes.
Chest: Lungs clear. Thorax symmetrical, respirations even and symmetrical.
Cardiac: Heart regular, questionable click, no JVD, no carotid bruit.
Breasts: Soft, symmetrical, without lumps, no discharge.
Peripheral vascular: Pulses palpable 1-2+, no peripheral edema, extremities warm and pink. No carotid, femoral, or abdominal bruits.
Abdomen: Flat, bowel sounds present x 4, no tenderness or guarding on deep palpation, no palpable masses no hepatomegaly or splenomegaly.
Genital: Vulva and labia without masses, lesions. No vaginal discharge.
Lymphatic: No palpable lymph nodes in neck, axillary, epitrochlear, or inguinal areas.
Musculoskeletal: Full ROM arms and legs, right hand grasp weak, minimal use of right hand, ambulates with full assistance, holding on to person with both arms to maintain balance. Right leg decreased strength, drags along floor while ambulating, decreased ability to turn right foot with pivoting. Gait slow, shuffles, small steps.
Neurological: Alert, flat, expressionless affect, verbal responses slow, one word responses “yes”, questionable slight right facial droop, decreased strength in her right extremities. Unable to do mini-mental due to lack of verbal responses.
Psychiatric: Patient appears content and peaceful, no symptoms of depression or anxiety.