AFFECTED PERSON HEALTH EXAMINATION
Student's Brand: Antonina Polukhina
Clinical Service: NCMC
PHYSICAL ASSESSMENT: Individual Initials: S i9000. E. Age group: 58 sumado a. o. Sex: Female Admitting Diagnosis: weakness/dizziness
Vital Indications: Temp. 97. 4, Heart beat 106, Respirations 18, BP 118/56 Ht/Wt/BMI: Height sama dengan 167. 64 cm, Pounds = 84. 878 kilogram, BMI 40. 2
Skin/Wounds: (Skin turgor; presence of any epidermis breakdown; sillon; wounds. ) Subjective: individual denies any skin breakdowns.
Objective: leg skin is shiny and has several enlarged veins, otherwise, epidermis is pale and consistently pigmented, no lesions or excoriations, very good turgor. Fingernails or toenails are lumination pink, stick to nail bed with 160-degree angle. Hair is usually grey, shiny and full; amount and distribution appropriate for age and gender, simply no flaking. Saline lock, proper antecubital, obvious, intact, small bruising, although no sighs of infiltration or inflammation. Eye, Headsets, Nose, & Throat: (PERRLA; general hearing; nasal congestion/drainage; mucus membrane layer color/moist; problems of difficulty swallowing. ) Subjective: individual has spectacles, denies hearing problems, nasal traffic jam. Patient says she cannot swallow her food except if it's cut and grinded, no tonsillectomy.
Target: PERLA, reading intact, nasal patency X2, mucous membranes are wet and green. Gag response intact. Thyroid gland is not really enlarged. Soreness Status: (Level of soreness; location, intensity, characteristics, activities which cause/worsen pain; activities which reduce pain) Very subjective: patient gripes of belly pain, nausea, and heart problems. C: lifeless
To: this morning
M: chest, back, stomach
S: almost eight
P: strolling makes it worse, but it's tolerable when she is during sex A: nausea, dizziness
Target: patient is uncomfortable when getting up from your bed, grimacing, patient is usually nervous.
PHYSICAL ASSESSMENT: continued
Heart: (Rate & rhythm; presence of conditional sounds (murmurs); peripheral signal вЂ“ power and equality) Subjective: individual states the lady had MI, valve replacement unit surgery, takes Coumadin (bruising), chest pain, hypertonie, patient claims she has good blood clots.
Aim: prosthetic mitral valve, heartbeat are bilaterally equal but weak 2+, prolonged capillary refill, telemetry SR, last BP 118/56, INR five. 0(H), PT 54. several (H), Hgb 10. zero (L), xray mild cardiomegaly, Respiratory: (Rate; presence of adventitious sounds вЂ“ examine front/back/sides (wheezes, crackles, etc); use of accessory muscles; grievances of SOB; use of oxygen) Subjective: sufferer states she has chronic bronchitis, denies SOB right now, individual states your woman had pneumococcal and influenza shot.
Objective: frequently coughing, COPD (bronchitis), ches x-ray is clear, pulse oximetry 92, fresh air source space air. GI: (presence of bowels noises вЂ“ all four quadrants; issues of diarrhea/constipation; last bowel movement; occurrence of belly distension/tenderness; health assessment) Subjective: patient acquired weight loss surgical treatment, patient says that last bowel activity was the other day, denies diarrhea/constipation.
Target: CT abdomen/pelvis lap band surgery, cholecystectomy, abdomen is definitely soft, nontender, bowel sound are lively and within all 4 quadrants. Endocrine: (History/treatment/symptoms of Diabetes; thyroid, parathyroid or adrenal disorders) Subjective: patient denies diabetes and other endocrine disorders.
Aim: Glucose 121, thyroid is definitely not increased.
Nerve: (Oriented X3; DTR's; Glascow's coma scale) Subjective: sufferer states " Name is S. Elizabeth., date of birth XX/XX/XXXX, I'm at the hospital. вЂќ
Objective: individual alert and oriented X3, Glasow's sama dengan 15, correct foot neural damage, feeling in right foot about 10 %. Muscular/Skeletal: (Extremity strength вЂ“ good and similar; ambulation вЂ“ independent/ with assistance/non-ambulatory; ROM) Subjective: patient states that she's employing walker. Patient verbalizes that it can be difficult to handle activity restriction, patient states she...
References: Gulanick, Meters., Myers, M. L. (2013). Nursing attention plans. Analyze, interventions, results. USA: Mosby.