Lee March 2 CP 1
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1 10/07Rev & Approved RN Program Director & Faculty 9/07 STUDENT NAME: Frances Lee DATE: March 2, 2011 PATIENT INITIALS: L.S. AGE: 78 PAIN: No Pain (Is patient experiencing any pain?) CHIEF COMPLAINT: Altered Mental Status HISTORY OF PRESENT ILLNESS In the last two days patient¶s daughter states her f ather has lost track of time and appears to be co nfused. PAST MEDICAL HISTORY Anemia; Diabetes Mellitus Type II; Co ngestive Heart Failure CURRENT ORDERS DIET: Pureed Diet ACTIVI TY: Bed Rest TREATMENTS: Wound care right heel, Oxygen 2 Liter per min. DEVELOPMENTAL ASSESSMENT PIAGET¶S STAGE: Formal Operations: (adolescence) This stage brings co gnition to its final form. This person no longer requires concrete objects to make rational judg ments. At this point, she is capable of hypothetical and deductive reasoning. Teaching for t he adolescent may be wide-ranging because she 'll be able to consider many possibilities from several perspectives. RN PROGRAM CARE PLAN # 1 ALLERGIES: No known allergies LMP: n/a (mark n/a if not applicable) GRAVIDA: n/a PARA: n/a AB: n/a PERCENTILE: n/a HEIGHT: 64 inches WEIGHT: 132 kilograms Body Mass Index: 40
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