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92-year-old client admitted into rehab following a cerebral infarction
with hemi paresis affecting right dominant side. Past medical history of
hypo-magnesium, age related, osteoporosis, unspecified, glaucoma,
primary hypertension currently taking Metoprolol tartrate 25mg. Diet
regular chopped thin liquids appetite is good. Dentures noted upper and
lower. Patient has weakness on right side due to hemiparesis. patient
ambulates using wheelchair. states, “I can’t move my right side at all “
Patient is unable to perform ADLs without assistance. Patient is
incontinent of bowel and bladder and wears a brief . Patient states “I
cannot feel when I have to go.” She is awake, alert and oriented x3
speech is clear and she is able to follow commands. Unequal hand grip.
Vital signs: Temp-97.6 HR-70 RR 17 BP 130/50 O2 Sat 96% on room air.
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