Due to retardation was unable to follow commands or communication; head noted as hydrocephalic; pupils equal and reactive to light; skin cool and dry; lips dry and cracked; inspection of month mucosa dry with caregiver stating she has dental caries and some gum redness; caregiver noted difficulty swallowing and extremely limited ability to mouth words; left upper back presented with a stage III pressure ulcer; ecchymosis noted on upper right arm; limited ROM with hands, arms, legs, feet, and neck due to contractures; patient moaned when the abdominal region was palpitated or when moved to right or left side; edema x2 noted in extremities; IV site showed no redness or infiltration; turgor x2; no cyanosis; slight ascites noted in abdomen; bowel sounds low x4; abdomen distended and soft with last bowl movement two days prior to this assessment; urine contained in Foley was clear and pale yellow; capillary refill x2; respirations were shallow with O2 level of 97 on 3L of moisturized oxygen via cannula; lungs sounds were coarse in both lungs at bases; heart tones normal; totally dependent for ADL's; caregiver has a signed DNR (do not resuscitate) order; unsure of pain level due to patient's inability to communicate and dependent on facial grimace or moaning along with input from caregiver
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Medical History .
Three weeks prior to this admittance, this patient spent 3 weeks in the hospital because of aspiration pneumonia. Per her caregiver, this is the third such incident in the past four months. .
Patient's medical history includes developmental delays, tuberous sclerosis, tachypnea, tachycardia, gallstones, dilated ureter, uterine fibroid, bilateral pleural effusions, a seizure disorder and diabetes insipitus. A pneumothorax occurred approximately 2 years ago. The seizure disorder is controlled with the use of anti-seizure drug therapy. Diabetes Insipitus is treated with vasopressin and DDAVP.
