Difference between revisions of "Symptoms"

Revision as of 07:40, 9 June 2015

Patient reported symptoms can affect a patient's overall health and well-being. The symptoms are reported by the patient during the Well-Being Assessment or updated regularly through well-being status. Symptoms are typically addressed by assigning Care Goals and interventions and activities in the Care Plan.

Pain or Discomfort

General

• Muscles cramps or spasms (painful)
• Tenderness to touch
• Swelling
• Bruising or discoloration
• Stiffness or decreased movement
• Body aches
• Itching or burning

Head area

• Sore throat
• Headache
• Enlarged or swollen glands
• Ear ache
• Mouth, teeth or gums

Stomach Area

• stomach ache
• Menstrual cramps
• Bloating or fullness
• Pressure or fullness
• Gas

Chest Area

• Chest Pain
• Feeling heart pound or race
• Heart palpitations
• Indigestion
• Heart burn
• Shortness of breath
• Lung congestion

Other

• Joints
• Back
• Arms or legs
• Muscles other
• Other

Sleep & Fatigue

• Night sweats
• Trouble sleeping
• Sleepy all the time
• Unusual Fatigue

Visual Symptoms

• Skin ulcer
• Skin rash
• Lump or bulge
• Swelling
• Bleeding or wound
• Drainage or pus
• Vaginal discharge
• Visible deformity

Cold and Flu-like

• Fever
• Head ache
• Aches and pains
• Fatigue and weakness
• Extreme exhaustion
• Stuffy nose
• Sneezing
• High temperature or fever (warm to touch)
• Cough - productive
• Cough - dry
• Congested lungs

Abnormal Occurrences

• Numbness or tingling
• Dizziness
• Cough
• Fainting spells
• Nausea or vomiting
• Nasal Congestion
• Abnormal bowel movements (Change in bowel habits, Diarrhea, constipation, loose bowels)
• Abnormal urination (frequent urge to urinate, cloudy urine with strong order, pain during urination, frequent bladder infections)
• Weight - unusual weigh gain or loss
• Hair loss - unexpected

Mental Health

General/Other

Functional Limitations

Hearing

• Difficulty Hearing in some environments
• Absence of useful hearing

Walking

• Some difficulty without devices
• Some difficulty with devices
• Requires wheel chair or devices

Sleeping

• Trouble falling asleep
• Trouble staying asleep

Understanding (by care giver)

• Misses part of message
• Limited understanding
• Unable to understand

Communication (by care giver)

• Some Difficulty expressing needs and ideas
• Frequent difficulty expressing needs and ideas
• Very difficult to understand

Vision

• Large objects and print only
• Object identification questionable

Standing

• Need device assistance
• Unable with device assistance

Grip

• Limited
• Absent

Breathing

• Severe shortness of breath at rest
• Mild shortness of breath at rest
• Shortness of breath with minimal exertion
• Shortness of breath with moderate exertion
• SOB when climbing stairs
• Uses ventilator

Mobility Endurance

• Walk or wheel chair 50 feet
• Can't do it
• Only with rest

Sitting Endurance

• Tolerate sitting for 15 minutes
• Can't do it
• Only with support

Primary Mobility Mode

• Cane/crutch
• Walker
• Orthotics/prosthetics
• Wheelchair/scooter full time
• Wheelchair/scooter part time
• No movement from bed

Activities of Daily Living - Limitation

• Bathing and showering
• Shower/bathe requires transfer
• Wash face, hands, chest, arms
• Dressing (Upper body, Lower body, put on/take off socks and shoes)
• Self-feeding (not including chewing or swallowing)
• Movement from one place to another to perform activities
• Personal hygiene and grooming
• Toilet hygiene
• Toilet transfer - safely on an off

Mobility

• Lying to sitting on side of bed
• Sit to stand
• Chair/Bed to wheelchair
• Sit to lying flat on bed
• Roll left and right
• Bend and pick up objects

Transportation Mobility

• Unable to car transfer
• Wheel chair lift only

Instrumental Activities of Daily Living (IADLS)- Limitation

• Telephone (Answer phone, place calls
• Take medications as prescribed (oral, inhalants/mists, injectable)
• Make light meal
• Wipe down surface
• Light shopping
• Laundry
• Use public transportation
• Mange money and pay bills
• Use computer
• Use a smart phone

Instrumental Activities of Daily Living (IADLS)- Other

• Care of others (Family members)
• Care of pets
• Child rearing
• Maintain social relationships
• Community Mobility
• Maintain Financial Management
• Maintain Health Management
• Maintain Home Management
• Meal preparation and cleanup
• Maintain Religious Observances
• Maintain safety procedures and emergency responses
• Shopping