Biographical Data FRP is a 68-year-old single male born on March 7, 1947 in Marshfield, Wisconsin. He currently has Medicare part A and B as well as Medicaid and his code status is Do Not Resuscitate (DNR) and Do Not Intubate (DNI). FRP’s parents are both German immigrants, but FRP does not speak the language. He stated he speaks English and learned to speak a small amount of Filipino while stationed in the Philippines as a Columban priest. He taught sign language to deaf children and was a superior to 55 priests while there. He was the primary source of information with his medical records and his nurse as secondary sources. FRP was generally reliable but at times his medical record and the nurse contradicted his recollection of past
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He has poor balance and an unsteady gait. He requires a hemi walker, gait belt, hard brace for ankle support, and two assistive personnel when ambulating. FRP generally uses a wheelchair when he is out of bed. During morning care, FRP performs active ROM on his ride side while a CNA provides passive ROM on his left side. Assistance is needed when rising from a chair or toilet and he is unable to climb stairs. He has fallen several times by putting himself to bed. He requires a two-person assist and only makes small movements in bed. FRP is able to complete oral care with assistance, but all other self-care is provided by the CNA’s. A Fall Risk Assessment helps staff evaluate residents’ level of risk to prevent potentially life threatening falls. FRP was considered high risk on the assessment due to his left-sided weakness, use of ambulatory aids, impaired balance and gait, history of falls within three months, medications, medical diagnoses, and diminished safety awareness. Attached at the end is a completed fall risk assessment for …show more content…
He is also prescribed bisacodyl, Bismatrol/Bismuth, Milk of Magnesia, and Fleet enema as needed.
Bladder
FRP does not use a catheter or ostomy, but he uses incontinence briefs and is generally continent, but has occasionally been incontinent during the night. He denied bladder frequency, urgency, burning or stress incontinence. FRP stated he voids 5-6 times per day and has no history of UTI’s. His urine is clear but dark in color.
Bowel
FRP does not use an ostomy, is generally continent, but has been incontinent on occasion during the night. He denied chronic constipation, chronic diarrhea, hemorrhoids, straining, or pain during bowel movements. FRP said he has a bowel movement every morning and after lunch. His stool is normally large, soft, well formed and brown in color. There was no documentation of a hemoccult test in his chart and he did not recall having one done.
Visual/Hearing
He has poor balance and an unsteady gait. He requires a hemi walker, gait belt, hard brace for ankle support, and two assistive personnel when ambulating. FRP generally uses a wheelchair when he is out of bed. During morning care, FRP performs active ROM on his ride side while a CNA provides passive ROM on his left side. Assistance is needed when rising from a chair or toilet and he is unable to climb stairs. He has fallen several times by putting himself to bed. He requires a two-person assist and only makes small movements in bed. FRP is able to complete oral care with assistance, but all other self-care is provided by the CNA’s. A Fall Risk Assessment helps staff evaluate residents’ level of risk to prevent potentially life threatening falls. FRP was considered high risk on the assessment due to his left-sided weakness, use of ambulatory aids, impaired balance and gait, history of falls within three months, medications, medical diagnoses, and diminished safety awareness. Attached at the end is a completed fall risk assessment for …show more content…
He is also prescribed bisacodyl, Bismatrol/Bismuth, Milk of Magnesia, and Fleet enema as needed.
Bladder
FRP does not use a catheter or ostomy, but he uses incontinence briefs and is generally continent, but has occasionally been incontinent during the night. He denied bladder frequency, urgency, burning or stress incontinence. FRP stated he voids 5-6 times per day and has no history of UTI’s. His urine is clear but dark in color.
Bowel
FRP does not use an ostomy, is generally continent, but has been incontinent on occasion during the night. He denied chronic constipation, chronic diarrhea, hemorrhoids, straining, or pain during bowel movements. FRP said he has a bowel movement every morning and after lunch. His stool is normally large, soft, well formed and brown in color. There was no documentation of a hemoccult test in his chart and he did not recall having one done.
Visual/Hearing