NURSING ASSESSMENT

PATIENT NAME: Aldhaheri, Saeed Obaid THIQA CARD NO.:1665660

AGE: 95 SEX: Male STATUS: Active
DATE OF BIRTH: 01/08/1920

DATE & TIME OF ASSESSMENT: 29/04/16 9:00 am

PLACE OF ASSESSMENT: AL Towayya, Al Ain

CHIEF COMPLAINT/S: bilateral knee pain and swelling, Left shoulder pain, weakness and fatigue

PRIMARY DIAGNOSIS: Renal Cell Carcinoma, Diabetes Mellitus, Hypertension

SECONDARY DIAGNOSIS: Rheumatoid Arthritis, Enlarged Prostate, Bilateral primary Osteoarthritis of knee

PRESENT CONDITION:

The patient is experiencing bilateral knee pain characterized by burning and popping especially on
Left knee, +swelling, +painful restricted flexion, body weakness and fatigue. Due to his pain the patient is
unable to turn to side in bed by himself, movements are also limited so he needs assistance when moving
and with his Activities of Daily Living.
PHYSICAL EXAMINATION:

ALLERGIES: None

GENERAL: Awake, slightly weak, can sit and stand with assistance, afebrile

VITAL SIGNS:
BP :120/80 PR :73 RR :19 TEMP : 36.5 C
CBG : 93 O2 SAT: 96%

INTEGUMENTARY: Dry, no jaundice noted, no bruises or contusions

HEAD/NECK: Normocephalic, a traumatic, non-icteric

EYES/EARS/NOSE/THROAT: Blind, slightly pale palpebral conjunctivae, no ear pain, no nasal

congestion, throat not hyperemic, no exudates, no erythema

RESPIRATORY: Equal Chest expansion, clear breath sounds

CARDIOVASCULAR: Regular cardiac rate and rhythm

GASTROINTESTINAL: Normoactive bowel sounds, + palpable mass at Right upper quadrant of the
adomen (about 10cm in diameter)

GENITOURINARY: with catheter attached to urobag (good urine output, yellowish)

NERVOUS: Oriented to place, person, time and coherent

MUSCULOSKELETAL: Upper Extremities: strong bilaterally

Lower Extremities: Weakness on both lower extremities, bilateral knee pain
LIST OF CURRENT MEDICATIONS:

1. Amlodipine 5mg, 1cap PO OD

2. Pantoprazole 40mg, 1tab PO OD
3. Aspirin 100mg, 1tab PO ODHS
4. Tamsulosin 0.4mg 1tab PO ODHS
5. Paracetamol 500mg, 2tabs QID PRN
6. Fentanyl Patch PRN for pain
7. Tramadol 50mg, 1cap PO BID PRN for pain
8. Diclofenac Na gel, apply externally QID
9. Ducosate Na, 1cap BID for constipation
10. Senna 1tab PRN for constipation

PLAN OF CARE AND MANAGEMENT:

 Foley Catheter care

 Strict intake and output monitoring
 Vital signs monitoring including O2 sat recording
 Bed positioning and mobilization
 Assistance in self-care due to age and health condition
 Assistance in ambulation as tolerated
 Blood sugar monitoring
 Providing pain management to help the patient feel comfortable
 Giving assistance in Activities of Daily Living

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