Client profile - CPE

1. Student Name: Dave Jay S. Manriquez Date: January 10, 2016
Class Number: 201509
Clinical Instructor: Catherine Overton
Client Portfolio
Patient: R.K. Room 255-2
Diagnosis (Top 5):
1. Diabetes Mellitus Type 2
- (Formerly noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes) is a
metabolic disorder that is characterized by hyperglycemia (high blood sugar) in the context of
insulin resistance and relative lack of insulin.
- Sign and Symptoms patient manifested: Irritability; Increase Blood Glucose; Confusion
- Medication: Metformin
2. Disorder of the Thyroid – Hypothyroidism
- Hypothyroidism, orunderactive thyroid, develops when the thyroidglandfailstoproduce or sec
rete as much thyroxine (T4) asthe body needs. Because T4 regulates such essential functions as
heart rate, digestion, physical growth, and mental development, an insufficient supply of this
hormone can slow lifesustainingprocesses, damage organsand tissuesinevery partof the body,
and lead to life-threatening complications.
- Sign and Symptoms patient manifested: Fatigue; Increase Sensitivity to Cold; Dry Skin; Puffy
Face; Unexplained Weight Gain; Muscle Weakness, Aches, Tenderness; Constipation; Anxiety
and Depression
- Medications: Levothyroxine (Synthroid); Mirtazepine; Quetiapine; Sennosides
3. Congestive Heart Failure
- A weaknessof the heartthatleadstoabuildupof fluidinthe lungsandsurroundingbodytissues.
- Sign and Symptoms patient manifested: Fatigue; Dyspnea; Dependent Edema; Weight Gain;
Increase Peripheral Venous Pressure
- Medication: Furosemide, Spironolactone
4. Acute Renal Failure
- Abrupt loss of kidney function, resulting in the retention of urea and other nitrogenous waste
products and in the dysregulation of extracellular volume and electrolytes.
- Sign and Symptoms patient manifested: Edema and Fluid Retention
- Medication: Furosemide
5. Hyperlipidemia
- Is too muchcholesterol inthe blood.Cholesterol isawaxy,fatproteinmanufacturedbythe liver
and is essential for healthy cell membranes, hormone production, and vitamin storage.
- Sign and Symptoms patient manifested: Increase Lipid Profile, LDL and Triglycerides
- Medication: Diabetic Diet, previously has Atorvastatin but recently discontinued
Intervention Level:
Degree 3 – involves transfer to acute care if a person’s illness cannot be treated in the home. It
involves no attempts at resuscitation.
Allergies: Amiodarone, Ciprofloxacin
Report Information: Pacemaker
Priority Assessments:
1. Quick Priority Assessment

2. - Airway and Breathing is good and regular. Circulation is good,capillary refill less than 3 seconds
inboth and lowerextremities.Vital signswithinnormal range.Skinisingoodcondition,warmto
touch, and flesh tone. No in and out. Patient is conscious, oriented to time, place, and person.
Denies any pain.
2. Peripheral Vascular Assessment
- Lower extremities is warm to touch, flesh tone, has sensation. Pedal pulses are palpable and a
little bitweak.Presence of non-pittingedemanotedonbothfeet.Noswellingandrednessbelow
the legs.
3. Abdominal Assessment
- No presence of scars, and it is round. Not distended and bowel soundsheard in four quadrants
during auscultation. No pain noted during palpation.
4. Respiratory Assessment
- No adventitious breath sound heard upon auscultation anteriorly and posteriorly. Although I
heard some sound during inhalation but not really significant that can interfere with her
breathing.
5. Full Nursing Assessment
6. Complete Vital Signs
- Vital signs within normal range.
7. Transfer Assessment
- Has the strength to move independently but show weakness on her legs. Patient still need
assistant in moving from bed to wheelchair and the reverse.
Medications:
1. Metropolol
2. Memantine
3. Mirtazapine
4. Ramipril
5. Furosemide
6. Ipratropium (Atrovent HFA)
7. Sennosides
8. Metformin
9. Spironolactone
10. Digoxin (Toloxin)
11. Xarelto
12. Glyburide
13. Levothyroxine (Synthroid)
14. Quetiapine
Mobility Transfers: Walking Aid, Independent
Positioning: Need Assistant
Personal Care: Independent
Bath: Need Assistant
Elimination: Goes to Toilet
Nutrition: Diabetic Diet/ Independent to Eat
Safety/Assistive Devices: Walking Aid
Dressings: None
Treatments/Tests/Lab: None
Daily Activities: Need Assistant 1 Person
Vital Signs/Routine Assessments: Yes

3. Communication: Communicate Well, Cognitive
Person centered care was delivered considering culture and diversity:
It is very important to put the patient as the top priority above anything else. Don’t interfere
personal beliefsandvalueswhile caringfor the patient. Since the facilityispracticingthe Jewishculture
and beliefitisbettertoobserve andrespectit.A goodexampleof thisisduringfeedingtimeatbreakfast
where Iusuallyaskmypatientwhatshe prepare toeatfirst,whatfoodIcan mix together,if she likesjam
or butter on her bread, if she likes milk on her coffee,if she wantsme to stay while she is eating or she
wants me to leave. Thingssuch as like this and respecting the decision of your patient will really goesa
longway.Buildingrapportwithourpatientisourobligation.AnotherexamplethatIcan site outisduring
bed bath, where my patient doesn’t want me to wash her private part. What I am doing is that I make
sure that I provide herwithprivacyby coveringher withtowel,Iprepare her clothesat the side before I
call for help from the care aide or one of my lady classmates to wash her. There are also times that she
wants to wake up late so I give her that space but I am always reminding her that she needs to get up
before 9amand be readybefore hercompanioncomes.Becauseme doingall of this,Ithinkmypatientis
startingto like me.She isstartingto trust me.She isnow talkingtome notthe same as we firstmet that
she was really irritated and complain a lot even with a simple touch.
The learner applied knowledge, skills and clinical decision making-making:
The knowledge that I learned from school I am applying it now. In regards to communication,I
make sure that the patientunderstandme by not talkingso fast, loud enoughfor themto hearme, and
ingivinginstructionIamalwaysdirecttothe point.Incommunicatingwiththe staff nurseandcare aides,
I tried always to be professional discussing only what concern the patients. In regards, to my learned
nursingskillsIamapplyingiteverydaysuchas the assessments;thisalreadyincludevital signsandfocus
assessment to master it. In terms of decision making, I leave the patient to decide on how I will do her
care. Off course I do still set that limit but as much as possible I am encouraging the patient to make
decisionhowshe will goingtoreceive hercare.Iwantmy patienttofeel thatshe isin control,thatthisis
herhome,she isindependentandshe onlyneedme togiveherassistant. Withmedicationadministration
it ismy obligationtostudyand do researchon the diagnosisof the patientandrelate those drugs whyit
is ordered, on how it can help alleviate the condition of the patient.
How you worked to strengthen your client’s self-care capacity rather than acting or doing
for the client:
Since mypatientisstill cognitive andcanfollow instructions,Icaninstructher to do simple tasks
that she can tolerate onherown.Such as combingherhair,washingherface and arms witha towel,and
buttoninghershirt. Doingthisgivesherthe sense of control andthe feelingof beingindependent.While
on bed I can instructmy patientto stretch her arms and bendher kneesmore oftenas a form of simple
exercise to promote muscle strength and good circulation. On transfer from bed to wheelchair, I will
encourage my patient to stand at her own strength and pace, and me just standing at her back guiding
her to prevent any fall.

4. Client Profile
Patient: J.S. Room 255-1
Diagnosis (Top 5):
1. Frontal Lobe Dementia
- Refers to a group of disorders caused by progressive nerve cell loss in the brain’s frontal lobes
(the areasbehindyourforehead),whichvariablycause deteriorationinbehaviorandpersonality,
language disturbance, or alterations in muscle or motor functions.
- Sign and Symptoms patient manifested: Loss the ability to understand and formulate words;
Speaking labored and ungrammatical; Muscle weakness and wasting; Muscle stiffness and
difficulty walking
- Medication: Quetiapine
2. Primary Generalized Osteoarthritis
- Most commonform of arthritis.It occurs whenthe protective cartilage onthe endsof yourbone
wears down over time. Most commonly affect joints in your hands, knees, hips and spine.
Graduallyworsenwithnocure exists.Butstaying active, maintainingahealthyweightandother
treatments may slow progression of the disease and help improve pain and joint function.
- Sign and Symptoms patient manifested: Pain; Tenderness; Stiffness
- Medication: Acetaminophen
3. Hypothyroidism
- Hypothyroidism, orunderactive thyroid, develops when the thyroidglandfailstoproduce or sec
rete as much thyroxine (T4) asthe body needs. Because T4 regulates such essential functions as
heart rate, digestion, physical growth, and mental development, an insufficient supply of this
hormone can slow lifesustainingprocesses, damage organsand tissuesinevery partof the body,
and lead to life-threatening complications.
- Sign and Symptoms patient manifested: Fatigue; Increase Sensitivity to Cold; Dry Skin;
Unexplained Weight Gain; Muscle Weakness, Aches, Tenderness; Constipation; Anxiety and
Depression
- Medication: Levothyroxine (Synthroid)
4. Hyperlipidemia
- Is too muchcholesterol inthe blood.Cholesterol isawaxy,fatproteinmanufacturedbythe liver
and is essential for healthy cell membranes, hormone production, and vitamin storage.
- Sign and Symptoms patient manifested: Increase Lipid Profile, LDL and Triglycerides
- Treatment: Soft Diet
5. Hemorrhoids
- Are swollenandinflamedveinsinyourarms and lowerrectum.May resultfromstrainingduring
bowel movements. May located inside the rectum (internal hemorrhoids), or they may develop
underthe skinaroundthe anus (external hemorrhoids).Commonailmentsbyage 50, about half
of adultshave had to deal withthe itching,discomfortandbleedingthatcan signal the presence
of hemorrhoids.
- Sign and Symptoms patient manifested: A lump near the anus; Bleeding; Irritation near anal
rregion; Pain and Discomfort; Swelling around the anus
- Medication: Anodan HC; VitamiN B12
Intervention Level:
Degree 2 – gives direction to the care team to provide therapeutic measures in the home. This
includes medications as ordered and comfort measures. No attempt at resuscitation, no artificial
feeding, and no transfer to acute care except for fracture and uncontrollable bleeding.

5. Allergies: None
Report Information: None
Priority Assessment:
1. Quick Priority Assessment
- Airway and Breathing is good and regular. Circulation is good,capillary refill less than 3 seconds
inboth and lowerextremities. Vital signswithinnormal range.Skinisingoodcondition,warmto
touch, and flesh tone. No in and out. Very poor cognition, unresponsive.
2. Peripheral Vascular Assessment
- Lower extremities is warm to touch, flesh tone, has sensation. Pedal pulses are palpable and a
little bit weak. No edema noted on both feet. No swelling and redness below the legs.
3. Abdominal Assessment
- No presence of scars, and it is round. Not distended and bowel soundsheard in four quadrants
during auscultation. No pain noted during palpation.
4. Respiratory Assessment
- No adventitious breath sound heard upon auscultation anteriorly and posteriorly.
5. Complete Vital Signs
- Vital signs within normal range. Except for the blood pressure, systolic pressure quite high at
158/84 mmHG.
Medications:
1. Acetaminophen
2. Levothyroxine (Synthroid)
3. Lax a day (Polyethylene Gycol)
4. Vitamin B12 Preparations
5. Anodan HC - PRN
6. Vitamin D3 inactive
7. Quetiapine - PRN
8. Salbutamol Neb – PRN
9. Proshield plus ointment 1% - PRN
Mobility Transfer: Mechanical Lift 1 Person, Wheelchair, Partial Assistance
Positioning: Need Assistance
Personal Care: Need Assistance
Bath: Need Assistance
Elimination: Goes to Toilet, Yes: day and night
Nutrition: Need Supervision, Diet Regular, Significantly Overweight
Safety/Assistive Devices: Wheelchair
Dressings: None
Treatments/Test/Labs: None
Daily Activities: Need Assistant 2 Person
Vital Signs/Routine Assessments: Yes
Communication: Cognitive; Inappropriate Response
Person centered care was delivered considering culture and diversity:
It is very important to put the patient as the top priority above anything else. Don’t interfere
personal beliefsandvalueswhile caringfor the patient.Since the facilityispracticingthe Jewishculture
and belief itisbettertoobserve andrespectit. Since mypatientisnolongercognitiveandunresponsive,
itisstill importantforme tofollowwhatthe facilityisobserving.The firsttime Ifedthe client,Ipersonally

6. askedthe care aide assignedtoheronhow she is receivingherfood,whatcanbe mix andnot,what goes
firstandlast.Basically,whatIamdoingatfirstIam justobservinghow the care aidesassignedtohercare
for her, and from then I was able to get the idea and develop my own technique.
The learner applied knowledge, skills and clinical decision making-making:
Since my patient is no longer cognitive and responsive. It is important for me to watch for non-
verbal cues.Althoughmypatientstill respondtosoundandtouch itis reallydifficulttounderstandwhat
she wants. I needto be mindful if she is irritable andrestlessthere mightbe underlyingcause forit, she
mightpoohor urinatedon herbrief,especiallynow adays that she wasdiagnosisof havinghemorrhoids
andit isbleeding.A screamora moanmightbe myhintthatshe isexperiencingsomepain,thatshe need
a medicationtocontrol it. Performingfocusassessmenttoheris the priorityof my listand I am doingit
everyday.Inregardstodecisionmaking,Iamdecidingonbehalfof the client,butoff course Ialsoconsult
with the staff nurse and care aides to what is best for the patient.
How you worked to strengthen your client’s self-care capacity rather than acting or doing
for the client:
Since mypatientisnolonger cognitiveandresponsive.Ihave decidedtodomostof hercare with
the helpof the care aide,since the patientneedtwohelperindoingthe care. I am the one combingher
hair, and I do help in repositioning her while the care aide wash her body.