Reflecting back on my history taking, I think that I did pretty well. I listened attentively, maintained good eye contact, and let the resident express her concerns. The resident’s length of stay was more than a year. So, I mostly …show more content…
So, it took a lot of time. In addition, Ms. RS had a lengthy list of medications that required additional clinical monitoring. Thus, I got to learn the proposed monitoring for certain classes of medications (i.e., Dilantin and Digoxin q 1month; HgbA1C and Kepra q3 months, …show more content…
Unspecified Sequelae of Cerebral Infarct- Continue with preventative ASA. Continue to maintain safety and fall precautions.
8. Weakness- BLE weakness present. Continue to encourage participation in restorative nursing therapy. Maintain safety and fall precautions. Continue Tylenol Arthritis for pain.
9. GERD without Esophagitis- Controlled. Continue Protonix. Monitor for s/s of n/v/indigestion, and abdominal pain.
10. Unspecified Open-Angle Glaucoma, Stage Unspecified- Her vision does not interfere with the performance of her daily activities. Continue Brimonidine Eye Drops. Follow-up with Ophthalmologist as needed.
11. Heart Failure, Unspecified- No shortness of breath. Bilateral 3+ pedal edema. Continue Lasix and Potassium. Check CMP now then q 3months. Encourage resident to elevate legs at least 3x a day when in bed and w/c.
12. Unspecified Iridocyclitis (Uveitis)- Denies any complaints of pain in bilateral eyes. No drainage. Continue Cosopt Eye Drops and FML Forte Eye Drops. Monitor for vision changes. F/u with Ophthalmologist as needed.
13. Gout unspecified: controlled continue with allopurinol as ordered monitor for s/s of increase uric acid.
14. Constipation, Unspecified- Controlled. Continue MOM and