Psycho-Social Pattern FRP has been diagnosed with post-traumatic seizures and is currently taking Keppra, Lyrica, and Baclofen to control the seizures.
Mental Status FRP is alert and oriented to person, place and time. He is not comatose or stupurous, but at times seemed slightly confused when recalling past events. When speaking with him his speech is delayed and he speaks slowly. FRP has a good attention span and was able to follow a three-stage command when asked to raise his bed, put on his glasses and turn his light on so we could conversate. He demonstrated good short-term memory by telling me what day of the week it was. FRP also demonstrated good long-term memory by recalling where he was born.
Emotional Status FRP was very pleasant, cheerful and always cooperative with me. He is hypo-active, spending most of the day in bed other than getting up to have lunch in the main dining room. He stated sometimes he is very sad that he can no longer help people and that he cannot walk the way he did before. He also stated he always tries to make the best of situations and is very happy to be alive. …show more content…
He stated the pain initially began after his stroke. It gets worse when he sleeps with his legs crossed during the night. He rated the pain at a 3 on a 0-10 pain scale and said at times it has gone up to a 10, but he can tolerate the pain if it is below 5 on the 0-10 scale. He described the pain as numbness and then stabbing with a sensation of pins and needles. FRP stated, “ROM helps to relieve the pain along with Tylenol and Lyrica.” He also stated the pain causes limited mobility and at times he becomes agitated because of it. FRP stated he deals with the pain and lets the nurse know if it becomes bad. FRP said he tries to keep his legs straight during the night to prevent the pain. Attached at the end is a completed pain assessment for his foot
Mental Status FRP is alert and oriented to person, place and time. He is not comatose or stupurous, but at times seemed slightly confused when recalling past events. When speaking with him his speech is delayed and he speaks slowly. FRP has a good attention span and was able to follow a three-stage command when asked to raise his bed, put on his glasses and turn his light on so we could conversate. He demonstrated good short-term memory by telling me what day of the week it was. FRP also demonstrated good long-term memory by recalling where he was born.
Emotional Status FRP was very pleasant, cheerful and always cooperative with me. He is hypo-active, spending most of the day in bed other than getting up to have lunch in the main dining room. He stated sometimes he is very sad that he can no longer help people and that he cannot walk the way he did before. He also stated he always tries to make the best of situations and is very happy to be alive. …show more content…
He stated the pain initially began after his stroke. It gets worse when he sleeps with his legs crossed during the night. He rated the pain at a 3 on a 0-10 pain scale and said at times it has gone up to a 10, but he can tolerate the pain if it is below 5 on the 0-10 scale. He described the pain as numbness and then stabbing with a sensation of pins and needles. FRP stated, “ROM helps to relieve the pain along with Tylenol and Lyrica.” He also stated the pain causes limited mobility and at times he becomes agitated because of it. FRP stated he deals with the pain and lets the nurse know if it becomes bad. FRP said he tries to keep his legs straight during the night to prevent the pain. Attached at the end is a completed pain assessment for his foot