Assessment of Patient with Lung Cancer, COPD, and Dementia

Patient Assessment
Name
University Affiliation
Professor’s Name
Course Title
Due Date
Appendix D: Patient Assessment Assignment
Patient Assessment Assignment Guidelines
Introductory Summary
Patient C. is an 85-year-old female admitted to the long-term care (LTC) in DNR code and later hospitalized due to a right hip fracture from a fall at home. The primary diagnoses are lung adenocarcinoma and dementia, which promoted her admission to LTC and her fall. The secondary diagnosis is COPD. Before the fracture, she was living alone and functioning fairly well. Her children, PSWs, and the cancer assistance program support her. She was receiving meals on wheels. The patient reported lung cancer and COPD, but she does not remember how long. She was active in recreation programs within the community through Salvation Army before the accident. She decided to move to LTC as she is now wheelchair and bed-bound. Her primary language is English, and she is allergic to penicillin and sulfur.
Current Medications
  Plavix, one tablet (75 mg total) per oral once a day 
Hydromorphone 1 mg tablet, to take 0.5 tablets (1.5 mg total) by mouth, three times a day
Salbutamol (Ventolin) 100mcg, 1-2 puffs every four hours if needed
Fluticasone (Flovent) 250mcg, 2puffs, twice a week
Tiotropium (Spiriva Respimat) 2.5mcg, two puffs (5mcg total) once a day
Senna 8.6 mg tablet, one tablet (8.6 mg total) by mouth, once a day with breakfast
Lactulose 10 gram/15ml solution, take 15 ml (10 g total) per oral once a day if needed
Vitamin D3 1,000 units (25mcg) tablet, take two tablets (2,000 units total) by mouth once a day

Physical Assessment

  Vital Signs: BP-146/71, P-72, T-36.7, Resp- 18, O2-92%
The resident reported pain in her right wrist on a scale of 5/10. I Administered an analgesic, contacted the physician to obtain an X-ray order, and informed POA (Power of Attorney). 
Neurological Assessment: Mini-mental test revealed the resident is forgetful. However, she is alert and oriented with normal speech. The patient needs a reminder with daily activities and is at risk of falls based on her history. I spoke with other nursing staff and PSWs for residents’ daily activity reminders and cueing. 
PERRLA- Pupils equal in size in both eyes and normal reaction to light.
Cardiovascular Assessment: On auscultation, S1 and S2 sounds were normal, and rhythm was regular with no murmurs or extra sounds. Capillary relief took less than 3 seconds, and peripheral edema was absent. Peripheral pulses, such as dorsal and posterior tibial, were palpable but slightly weak.
Respiratory Assessment: The external chest is symmetrical in appearance without lifts. On auscultation, we detected slightly high-pitched whistling sounds. Respiration...