The nurse conducts a return home visit 3 months later on 68-…
The nurse conducts a return home visit 3 months later on 68-year-old male client with Parkinson’s disease and a history of falls. Nurses’ Notes 1000 – Initial post-discharge visit in the client’s home. Met with client and his son. The client has moderate stage Parkinson’s disease and lives with his adult son, who works full-time and provides supportive care. Client reports that he fell on the stairs, attempting to use the second-floor bathroom. Assessment findings: Client is alert and oriented to person, place and time Walks short distances using a walker without problem, but reports that he tires easily Resting tremors noted in both arms and legs Son reports client needs assistance with ADLs on days when rigidity is worse Client reports that he has not slept more than 2 hours per night since discharge 1100 – After a short rest, continued assessment. Blood pressure sitting 138/88, standing 116/60, complains of dizziness on standing Heart rate 86 beats per minute and regular Respirations 16 per minute and unlabored; breath sounds clear bilaterally Temperature 97.2F (36.2C) Strength in legs is diminished bilaterally, but client is able to bear weight using walker Range of motion is within normal limits but rigid in all extremities Client reports frequent urination, “I am sometimes unable to make it to the bathroom” Speech is slow and halted, but understandable Moderate, continuous drooling noted 3-month follow-up assessment Met with client and his son, who both report no falls since the last visit. Client is using the bedside commode during the daytime hours, and only uses the stairs in the evening to go upstairs to sleep. Client reports that he still sometimes feels dizzy when he stands up. Speech is very slow and difficult to understand, and son frequently answers for the client. Episodes of confusion and irritability have been noted during the evening hours. Client demonstrates ability to move within living space with the walker. Medications Lisinopril once daily for hypertension Carbidopa/levodopa 3 times daily to treat Parkinson’s symptoms Environmental Assessment Environmental assessment completed by walking through the home with the client. Client reports spending most of his time on the ground floor, aside from the need for toileting (bathroom is on the second floor with stair access). Floors are wood with no noted throw rugs. Walkways are clear of debris. The nurse returns in 3 months to re-evaluate the client. The statement below indicates that the client’s status has improved, true or false: The client has enrolled in an online yoga class and reports no falls within the last 3 months.