Difference between revisions of "Symptoms"

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==[[Mental Health]]==
 
==[[Mental Health]]==
  
==[[General/Other]]==  
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==[[General/Other]]==
 
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==[[Functional Limitations]]==
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===Hearing===
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* Difficulty Hearing in some environments
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* Absence of useful hearing
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===Walking===
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* Some difficulty without devices
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* Some difficulty with devices
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* Requires wheel chair or devices
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===Sleeping===
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* Trouble falling asleep
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* Trouble staying asleep
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===Understanding (by care giver)===
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* Misses part of message
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* Limited understanding
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* Unable to understand
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===Communication (by care giver)===
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* Some Difficulty expressing needs and ideas
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* Frequent difficulty expressing needs and ideas
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* Very difficult to understand
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===Vision===
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* Large objects and print only
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* Object identification questionable
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===Standing===
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* Need device assistance
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* Unable with device assistance
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===Grip===
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* Limited 
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* Absent
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===Breathing===
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* Severe shortness of breath at rest
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* Mild shortness of breath at rest
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* Shortness of breath with minimal exertion
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* Shortness of breath with moderate exertion
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* SOB when climbing stairs
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* Uses ventilator
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===Mobility Endurance===
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* Walk or wheel chair 50 feet
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* Can't do it
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* Only with rest
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===Sitting Endurance===
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* Tolerate sitting for 15 minutes
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* Can't do it
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* Only with support
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===Primary Mobility Mode===
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* Cane/crutch
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* Walker
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* Orthotics/prosthetics
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* Wheelchair/scooter full time
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* Wheelchair/scooter part time
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* No movement from bed
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==Activities of Daily Living - Limitation==
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* Bathing and showering
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* Shower/bathe requires transfer
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* Wash face, hands, chest, arms
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* Dressing (Upper body, Lower body, put on/take off socks and shoes)
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* Self-feeding (not including chewing or swallowing)
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* Movement from one place to another to perform activities
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* Personal hygiene and grooming
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* Toilet hygiene
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* Toilet transfer - safely on an off
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===Mobility===
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* Lying to sitting on side of bed
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* Sit to stand
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* Chair/Bed to wheelchair
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* Sit to lying flat on bed
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* Roll left and right
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* Bend and pick up objects
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===Transportation Mobility===
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* Unable to car transfer
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* Wheel chair lift only
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==Instrumental Activities of Daily Living (IADLS)- Limitation==
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* Telephone (Answer phone, place calls
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* Take medications as prescribed (oral, inhalants/mists, injectable)
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* Make light meal
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* Wipe down surface
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* Light shopping
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* Laundry
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* Use public transportation
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* Mange money and pay bills
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* Use computer
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* Use a smart phone
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===Instrumental Activities of Daily Living (IADLS)- Other===
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* Care of others (Family members)
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* Care of pets
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* Child rearing
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* Maintain social relationships
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* Community Mobility
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* Maintain Financial Management
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* Maintain Health Management
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* Maintain Home Management
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* Meal preparation and cleanup
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* Maintain Religious Observances
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* Maintain safety procedures and emergency responses
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* Shopping
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Revision as of 09:26, 9 June 2015

Patient reported symptoms can affect a patient's overall health and well-being. The symptoms are reported by the patient with the Symptom Assessment, which is a component of the Well-Being Assessment. It will be updated regularly via the well-being status. Symptoms are typically addressed by assigning Care Goals and interventions and activities in the Care Plan.

Symptom Assessment

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