PERSONAL ORGANIZATION PLAN (POP) Name:

Resident: Age: M.D. Nurse: Date: No info provided Medical Dx: M.P a male cleint 94 y/o,diagnosed with Parkinsons Disease- is a progressive, degenerative neurologic disorder of basal ganglia function characterized by tremor (shaking), muscle rigidity, bradykenesia(slowness of movement) ,and postural instability(Port& Martin 2009) Dolores RN Past Medical History: -secondary to osteoporosis-define as porous bone, is a metabolic bone disorder characterized by loss of bone mass, increased bone fragility, and increased risk of fracture.(Lemone , p1338) Weight: 86.6kgs Activity status:Extensive two person assist Diet status:NPO not dietary intake? Code Status: full code

Length of stay/Admission date: admitted 2/19/2008 Allergies: clam, chowder, shelfish, resistant to other balactam antibiotic Report Date: Lab Test/Procedure: 02/18/2013 Growth & Development:frail older adult- belong to older adults with decline physical functioning that can result in increased vulnerability to illness.(Kozeir, p348) Dressings/Treatments: Peg tube site should be monitor Tube-feeding: frequently for signs of skin irritation, and if its intact at all Peg- tube-Jevity-1.5 times 150cc/hr to sun intermittent feed, as ordered. IV Other: UrineBM- had large Emesis; Other: Fluids- flush Output: urine is bowel which is no N/a 150cc re normal pale in normal,abomen concern /post amout color is soft to feeds and no odor palpate.no additional color nomal concern. He is 50 cc of amount on Glycerin

IV solutions/rate: N/A Intake: PO Fluids NPO

no supp and fleet concern enema if no BM for 3 days, to relieve of constipation by other meds, but he has no problem so far with his bowel movement base on his data. Vital BPTemp- Pulse-84 Resp.20 O2satPain Level no IV site- Dressing: Signs latest36.8C 93% pain as patient n/a n/a 128/70 manifested. Head-to-Toe Assessment Neuro/Mental Status: Loc- patient cannot talk ,but Gastrointestinal: bowel movement regular, he response to any pain stimuli, usually making a usually once a day. No gurgling sound , no bruit, moaning sound if patient is not feeling well or in abdomen is soft to palpate, normal size, shape, pain, he response to verbal command by pinching and symmetry, peg tuber site is intact , clean your hand . and dry, and no distention. (no bowel sounds? did you listen for long enough?)

water pre and post each feeding

Cardiovascular: with aging ventricular wall thickens, left atrium increases, and mitral valve closes more slowly, (Nursing Assessment practice p 28I) in this case his blood pressure is normal, no chest pain, or discomfort ,no dyspnea, jvp, is not distended and has one pulsation light upon inspection, no abnormal sound no need for this information in the POP, only your assessment findings for the resident.

Genitourinary: with normal urine color (pale yellow)normal amount as evidenced by full incontinent has changed every shift, no difficulty or burning with urination ,no diarrhea, no increased frequency ,

Respiratory: patient has no signs of distress , no dyspnea, ,no used of accessory muscle while breathing, rhythm and is regular no murmur sounds in both lungs with normal o2 sat of 93%,retractions are absent. Breathing is not in labor. And no clubbing of fingers.

Musculosketal/Integumentary: stiffness on upper ext. related to disease condition (osteoporosis) impaired physical mobility muscle are weakness, inability to perform self care ,patients needs extensive assistance. Assistive device is use to transfer patient from bed to wheelchair and vice versa. Skin color equal on both lower and upper extremities.

Nursing Diagnosis (es):

1. Risk of for fall due to tremors/severe lower limbs weakness secondary to Parkinsons Disease, bed maintain at the lowest position during the night, floor pad at bedside, monitor clients frequently during the night. 2.Risk to develop mouth thrush [mouth sore/laceration] as patient is not taking anything by mouth. Provide oral care by using a sponge tooth brush to avoid to dryness of the oral cavity. Provide just the nursing diagnoses here, not the interventions. 3.Imbalance nutrition, less than the body requirement related to difficulty of swallowing and chewing peg tube feeding on regular basis as ordered. if on PEG tube feeding, resident may be receiving adequate nutrition as he was seen by dietitian. [but good nursing dx.] Your nursing diagnosis still need a little more work, but improving from previously. Time 0730 0800 Nursing Interventions Received patient assignment and gather information of the assign patient Started the feeding via p-tube Assessments Review the patient plan of care, bed side care started. Taken vital signs and performed head to toe assessment. Placed patient in semi sitting position while having his feeding Two person assist needed to turn patient and used ceiling lift to transfer the patient to wheelchair and vise versa patient is soaked with urine and had a large bowel movement, By the helped of two person were able to perform bed bath Used of ceiling lift to move client from bed to w/chair. Inclined the chair, patient is more relaxed. I and my buddy nurse discussed if the goal is met according to what is in the plan of care. To maintain socialization for stimulation. In cognition.

01100

Perform morning care with the help of my buddy nurse.

We gave bed bath for the patient Place client in w/c comfortably

Stared to document all the information that was done for the day. 1200 \Bring patient to the therapy session

Nursing Documentation Received patient in bed asleep sleeping on bed, at lowest bed position, breathing normally, with pegtube attached at the RUQ of the abdomen , dry , intact and clean. No abdominal distention vital within the normal. Patient has impaired in verbal communication, patient cannot talk ,but with good verbal and stimuli response, usually normally just makes sound if feels any pain or discomfort (moaning). G tube place with abdominal binder (loosely HS) to protect from pulling out the tube. Total assist x2 person, to turn and repositioned at least twice during the shift, the focus on goal to give comfort to the client by offering musical therapy group to give a relaxation period.In relation to cognition ,mood ,physical behavior is concern, when patient start to grab, staff put something like ball or wash towel to hold on, to distract attention , sometimes patient is agitated and resistance to any care. Provide with comfort measure to lessen agitation. You must maintain calm environment at all times and voice should be in modulated to avoid refusal, any time you will give care. Resident has art therapy every as per social activity. noted resident moaning means in pain, Tylenol 650 elexir given via pegtube, since we know that PD have complex and multisystem needs, and so deficit in mobility and self- care is very important ,due to declining process . The focus is to maintain adequate needs of the resident such as nutrition, and skin integrity, mobility as per ,is included in the plan of care. Good nursing documentation.