Luther Abara is a 79-year-old man who
Luther Abara is a 79-year-old man who lives with his daughter in North Vancouver. He loves watching sports on TV, especially baseball and basketball. Since his CVA he has not been very active and requires lots of support from his daughter. A support worker comes to the home three times a week to help him with bathing and hygiene. Medical History Mr. Abara has been treated for hypertension and high cholesterol since 2010. In 2018 he had a CVA which left him with some weakness in his right leg and has affected his speech. Recent Events For the last five days, his daughter has noticed that he has been sleeping for most of the day and talking less than usual. He has had a very limited appetite. He has had a weak cough, but he tested negative for COVID. Two days ago, she noticed he was quite restless and confused. She decided to bring him to the ER for assessment as his family doctor was not available until next week. In the ER he was found to have an Sp02 of 86% and RR of 24/min. Upon CXR he was diagnosed with pneumonia. He was admitted to the medical ward for treatment. Patient Information ( Secondary Data) Name: Abara, Luther Sex: M DOB: 04/06/1943 Age: 79 PHN: 8967 876 123 Admission Date: 2 days ago Communication: English Allergies: NKA Code Status: DNAR-M3 Next of Kin: Abara, Salome Rel: Daughter Contact: 778-XXX-XXXX Admitting Service: Medicine Diagnosis: Pneumonia (COVID NEG) Isolation: NONE Safety: fall risk Health History: HTN/CVA (2018)/BPH/GERD ADLs: 1 person assist Nutrition: DAT-soft texture, thickened fluids Low Na+ Mobility: AAT; uses a cane 1-2 person assist Tubes/Lines/Drains: IV Left FA #20 Upcoming tests: Swallowing assessment CBC, Renal panel Consulting services: Physiotherapy Occupational therapy Estimated Discharge Date: TBD Medications: Levofloxacin IV q6H Ramipril 10mg PO BID HCTZ 50mg PO daily Enoxaparin 40mg SC daily Esomeprazole 40mg PO daily Tamsulosin 0.8mg PO daily Tylenol plain i-ii tabs PO q4h PRN Other Orders: Keep 02 sats >92% ,IV D5NS with 20mEq KCL at 75cc/hr ,Monitor postural vital signs BID Shift Change Report: Mr. Abara slept well. Oriented x 3 last night. His respiratory status has improved significantly—now on 2l 02 via NP. RR= 18. 02 sat 92-93%. Coarse crackles in lower lung fields bilaterally. Coughing up brown sputum frequently. Please encourage DB&C. IV infusion continues as intake low. Urine output low. BP remains elevated at 160/75 mmHg. Afebrile. Swallowing assessment with OT scheduled for this morning at 1000. Crush medications. Mobilized to chair yesterday with ceiling lift. Primary Data (SUBJECTIVE) Disposition : You are cooperative with care. You are sleepy. You don’t speak too much-only answer questions. You speak slowly. You are unemotional. Tubes, Lines & Drains : IV is NOT painful. CNS: Oriented x 3. No pain. No altered sensation in body. RESP: If asked, you feel a bit short of breath. Frequent productive cough. No chest pain or pressure. CVS : No chest pain You feel like you are a comfortable temperature ABDO : No pain or nausea. No appetite You don’t know when you last had a BM You don’t know about your urine output. No tenderness on palpation MSK/SKIN : No concerns that you are aware of Feel can feel “numb” sometimes Primary Data ( OBJECTIVE) Vital Signs: BP 155/75 ,HR 88 ,RR 18 ,Sp02 94% on current 02, Temp 36.5 General Appearance : Sleepy ,Calm ,No apparent distress Tubes, Lines & Drains : IV site is free from redness/swelling CNS : PERRL at 3mm ,Face movement symmetrical CVS : Apical pulse as per mannequin ,Skin colour normal in core UPPPER EXTREMITIES : Normal colour ,Warm ,Strong hand grips bilaterally ,Cap refill 3 secs bilaterally , Radial pulses strong bilaterally LOWER EXTREMITIES : Colour as per photo ,Cool to touch ,WEAK right DF/PF ,Moderate LEFT DF/PF ,Pedal pulses very weak bilaterally (+1) ,Cap refill 4 secs bilaterally ,Calves as per photo RESP : Some use of accessory muscles visible ,Chest expansion symmetrical ,Breath sounds as per mannequin ABDO : Abdomen obese and soft ,No scars, lumps, or skin issues ,Bowel sounds No masses on palpation ,Bladder not palpable MSK/SKIN : No issues on backside ,No areas of skin breakdown – Based on the data collected from Mr. Abara’s information, write entry for his chart about THREE areas of focus using the F-DAR format. SCIENCE HEALTH SCIENCE NURSING NURSING N3160
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