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Focus Assessment

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Focus Assessment

Date: 11/14/2013 Client Initials: B.M Age:93 Sex: F Code Status: DNRCC-A
Primary Medical Diagnosis: CVA Allergies: Sulfonamides, iodine, iodine contrast dye.
Significant Medical History and/or Other Medical Diagnoses Hypertension, Hyperlipidemia, Colon cancer, Uterine cancer, CVA, legally blind, macular degeneration, Ileostomy, renal insufficiency.

Current Treatments & Interventions for the Client Anticoagulation therapy, Transfer with 1 person assist, physical therapy consult, occupational therapy consult.

Recent Tests & Procedures and the Results CBC: High hematocrit, low platelets, normal WBCs CT Scan of Head: 2 areas of ischemic attacks. EEG: Signs cerebral ischemic attacks parietal and occipital lobes.
Assessment
Focus Assessment (specify): | Data: Pt. stated she woke up during the night and noticed the right side of her body was weak and she found it difficult to move her right arm and right leg. Pt. brought to the ED where a CT scan was performed. This showed areas of ischemic attacks. Pt. is alert and oriented to place and situation. The patient is aware of time but is unable to give the exact time. May or may not be attributed to her being legally blind. Pupils round equal and reactive bilaterally. Right hand grasp slightly weaker then left. Lungs bilaterally clear and diminished in bases. Bowel sounds active times 4 quadrants. Pt. has ileostomy which is pink, draining watery green and brown stool. Pt. has atrial fibrillation. Heart rate is irregular upon auscultation. Pt. right leg is weaker than left leg. Pt. has decreased ROM and foot push on right side. Pt. skin is warm and dry. Pedal pulses present bilaterally. PT. denies any pain at this time. Call light within reach and bed alarm is set. |

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