Patient’s initial: S.S. Date of Birth: 8/24/1939 Age: 82 Gender: Female Diet:

Patient’s initial: S.S.

Date of Birth: 8/24/1939

Age: 82

Gender: Female

Diet: Regular

Drug Allergies: Benadryl, Demerol, Penicillin

Full code: No DNR

Primary Diagnosis: Osteoarthritis

Secondary Diagnosis: Rheumatoid arthritis

Patient is also diagnosed with scoliosis, spondylosis without myelopathy or radiculopathy.

Current Status: Pain in the right shoulder, left and right hips, left knee

Current medication: Long term use of opiate analgesic.

Physical limitation: fall risk

Mental health limitation: Fully alert, but takes a minute to wake up due to side effects of medications. Does not like to be awaken too early until 8 A.M. Patient has no pose danger to self and others.

Health status: Needs assistance ambulating, bathing (every Tuesday, Thursday, Saturday), dressing, eating, grooming, toileting and transferring. Okay with Q2 Hour Check.

Skin integrity: No pressure ulcer/sore, just a massive bruise on the right leg.

Patient recently experienced signs and symptoms of nausea and vomiting, chills, fever, shortness of breath during the month of April.

Immunizations and vaccinations: Patient received all the recommended immunizations and vaccinations. Patient also had TB screening with negative infectious disease.

Plan of Care: Will have an in-house therapy upon discharge. Patient needs a sitter to check and take care/assist of her ADLs.