Case Study Of Miss Atkins

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Recommended: Patient compliance with medications

Patient Background Miss. Atkins is an 87 years old female African American admitted at (HCNR) nursing home on July 11, 2012; because Miss. Atkins can no longer care herself. She is under the care of Dr. Chai. Her medical diagnoses are dementia with psychosis, hypertension, Hyperlipidemia and arthritis. Miss Atkins Presently taking Simvastatin 20mg, Risperidone 1mg, and Tylenol 1000mg prn, aspirn 81mg, Lasix 40mg, and Norvasc 5mg. She is approximately 5’5’’ tall, weighs 167 pounds. She is alert and oriented x 2 with periods of confusion. Wonder guard to right wrist, due to several attempts made to elope. Miss Atkins, is incontinent of urine, and sometimes refuses care. She uses cane for ambulation and wheel chair for long distance; also she can ambulate on / off the unit with supervision. Diet: NAS chopped with ground meat, bread, and a soft …show more content…

I wash my hands, and instructed Miss A to seat on her bed. I position myself in front of Miss Atkins then start. SKIN (hands): dry and warm to touch, no discoloration, no mole, capillary refill < 3 second, good skin turgor, Wrinkle skin. VITAL SIGN: B/P 142/ 70, P72, T 97.8, R 18, O2SAT 100% room air. HEAD AND FACE: No mole or indentation to head, hair evenly distributed, with some hair loss to the center of her head, freckles, and wrinkles skin present, appears to be anxious. Trachea is position midline; with limits ROM of her head from side to side, forward and backsword. EYES: eyes are even with symmetrical eyebrows movement. Pupil reacts to light and accommodation, far sighted (using eye glasses). Conjunctivae sac pink, with white sclera, no drainage or redness noted. Eyelid meet together, eyelash evenly distributed. EAR: ear are equal in size, same color as face and intact. No lesion, tenderness or swelling; moderate cerumen present to B/L ear. NOSE: straight, no drainage or

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