DUE REAL 1
Name: Linda McCarthy
Age: 86 years
Provider: K. Townsend MD
Codestatus: DNI
BMI: 24.1
Allergies: penicillin, atorvastatin, red dye, latex
Admitweight: 145 lbs (65.8kg)
Linda McCartchy had a rough night. She was pretty restless and only slept two hours.
This morning she was having an issue with her hearing aids not working. They kept
whistling. I went to change the batteries, but she was out of them. Her family will be
bringing them in later today.
Nursing Assessments and notes
11/1
0700
Neuro/Cognitive: Alert and oriented to person and place. She intermittently
confused and called staff by the names of her children. Speech raspy. 4/5
strength in all extremities.
Cardiovascular: S1 and S2 heart sound present. Heart rate regular and even.
No edema was noted. Pedal pulses +2, radial pulses +3. Capillary refill less
than 3 seconds.
Respiratory: Even, regular, unlabored. Lung sounds wheezing through all
lung fields. Chronic dry cough. Wears 2 L via nasal cannula chronically.
Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended,
non-tender. Last bowel movement 2 days ago.
Genitourinary: Occasional stress incontinence.
Integumentary: Scattered bruising. Various stages of healing.
Sensory: Hard of hearing. Wears hearing aids and glasses.
11/1
0730
ADLs: Independent with utensil holders
Activity: Ambulated 100 feet with a roller walker
11/1
0830
Nursing Note: Client resting quietly in bed. Looking out the window, not
responding to staff prompts for verbal interaction. Moves all extremities
appropriately. Morning medications were administered without difficulty. Able
to state name but unsure of her birthday. Up in the hall with physical therapy.
Shuffling gait with use of a rolling walker.
11/1
1100
Nursing Note: RN called to bedside. The client stated that the staff took her
favorite earrings. Earrings were found in the client’s tissue box at the bedside.
11/1
2015
Nursing Note: Client evening hygiene offered. The client begins yelling, “No!
No! No!” as staff offer to assist with teeth brushing and denture care. Attempts
were made to deescalate the client and place her hearing aids so that she
could hear the conversation. The client begins attempting to hit and bite staff.
Client sitting in bed. Staff leave room to reduce stimulation.
11/1
2015
Neuro/Cognitive: Alert, oriented to self only. She believes it is 1965 and that
there are strangers in her house. Client calling out for her mother. Extremely
hard of hearing with hearing aids in place.
11/2
0700
Nursing Note: The client is awake in bed, staring around her room, rubbing
her eyes, and frequently yawning. Noted to have redness and purulent
drainage from right eye. Provider notified; prescriptions received.
11/2
0900
Nursing Note: Appetite poor, ate 5 small bites only, Drank a cup of juice.
Weight down. Will encourage protein supplement drinks between meals.
Date Intake Source & Amount
11/1 0700 Oral 240 mL
11/1
0900
Client Information:
Medical History: Presbyopia, bilateral cataracts, Alzheimer’s dementia,
hearing loss, hypertension, hyperlipidemia, osteoarthritis, ambulatory
dysfunction, chronic obstructive pulmonary disease
Medications:
● Rivastigmine 6 mg by mouth twice daily
● Lisinopril 20 mg by mouth daily
● Ezetimibe 10 mg by mouth daily
● Simvastatin 40 mg by mouth daily
● Docusate sodium 100 mg by mouth daily
● Polyethylene glycol 17 g by mouth daily – diluted in 8 oz of beverage
● Duloxetine 60 mg by mouth daily
● Artificial tears 1-2 drops into eyes PRN for dry eyes
● Oxygen 2L/NC PRN for difficulty breathing
11/2 0730 Prescriptions:
● Ciprofloxacin ocular ointment 0.5-inch right eye three times
daily
