Hairston -1- Clemson University NURS 319 Health Assessment Health Assessment Data Base HEALTH HISTORY (Subjective Data) Date: 2/25/2011 and 3/14/2011 Examiner: Jessica Hairston, RN 1. Biographical Data: Name: C.H. Phone: (XXX)XXX-XXXX Address: Greer, South Carolina, Greenville County Birthdate: 09/26/1962 Birthplace: Greenville, SC Age: 48 Sex: Female Marital Status: Married Occupation: Kindergarten Teacher Race/ethnic origin: Caucasian Employer: Greenville County School District 2. Source and Reliability: Patient, C.H., provided information regarding herself, who seems reliable. 3. Reason for Seeking Care: Well-Check Physical, No complaints at this time. 4. Present Health or History of Present Illness: At this time, C.H. is currently in a state of good health. Pt. denies complaints at this time. She is currently suffering from some sinus drainage due to seasonal allergies but it is easily relieved with an antihistamine. ***Update: For our second encounter, C.H.’s state of health changed. As pt. was walking out of her sunroom into her garage, she fell down two steps, landing on a concrete floor. Pt. bruised her left elbow and damaged tendons and ligaments in both of her ankles. Pt. currently has left arm in a compression wrap and sling and both ankles are in lace-up braces for support. Pt. is going to physical therapy one to two times a week due to injuries. Per pt. orthopedic doctor states she should have a full recovery after healing and physical therapy. The pain in her left elbow is localized and presents as a burning sensation. While in the compression wrap and sling, C.H denies pain in her left elbow. However when she takes it off, pain is immediate, 4 on 0-10 pain scale. At this time, C.H. states that pain in her ankles is diffuse and the quality changes from throbbing to pounding with periods of stabbing. Pain in her ankles is usually a 5-6 on 0-10 pain scale, with the worst pain experience at night after being on her feet all day. Hairston -2- 5. Past Health: Childhood Illnesses: Chicken Pox during school age years, denies Measles, Mumps, Rubella, Pertussis, Rheumatic Fever, Scarlet Fever, and Poliomyelitis Accidents or Injuries: 10/08- First Degree Burn on Right Wrist 3/09- Fall, Injury to Left Knee 3/11- Fall, Injury to Left Elbow, Left Ankle, and Right Ankle Serious or Chronic Illnesses: Adult Onset Asthma and Depression, denies diabetes, hypertension, and heart disease. Hospitalizations: 11/1991-3/1992: Admitted for infection of unknown origin, with few options left, doctors decided to do an exploratory surgery, at that point it was determined that during appendectomy (9/91), bile duct was nicked, bile had been slowly leaking into pts body for several months. All organs in patient’s abdominal cavity were covered with infection, the infection had to be scrubbed off of organs and from the abdominal cavity, bowel resection was performed due to damage from the infection, and cholecystectomy. Operations: 6/1986: Caesarian Section 5/1988: Caesarian Section 9/1991: Appendectomy 1-2/1992: Multiple Abdominal Surgeries including an exploratory surgery, bowel resection, cholecystectomy 11/2009: Left Knee Repair 11/2010: Oral Surgery 3/2011: Oral Surgery Childbearing History: Gravida: 2 Para: 2 Term: 2 Preterm: 0 Abortions: 0___ Pregnancies: Date of Delivery Gestational Age Wt. Type of Delivery Complications 06-20-1986 43 weeks 8 lbs. 14 oz. C/S None during pregnancy, labor, or after birth 05-09-1988 37 weeks 5 lbs. 10 oz. C/S *See below *Doctors suspect that C.H., came in contact with an unknown teratogen during the first trimester of pregnancy. During the third trimester of pregnancy, C.H. was informed of the abnormal fetal development and doctors suspected the infant would live only a few days after birth; however, she lived until she was three years old. Infant was born with multiple birth defects including: hydrocephaly, blindness, deafness, cystic fibrosis. Complications during postpartum period: Denies complications after first pregnancy. Multiple complications during postpartum period after second child was born related to the severity of child’s health conditions. Immunizations: Measles-Mumps-Rubella, Polio, Diphtheria-Pertussis-Tetanus, Small Pox, Hepatitis B Date of last Tuberculosis Skin Test: Negative, 0mm, about 12 years ago Date of last Tetanus Immunization: Unsure, Not within the last 10 years Date of last Influenza Immunization: 09/2010______________________ Hairston -3- Last Examination Dates and Results: Date Result Physical: 08/2010 WNL Dental : 03/2011 WNL Vision: 2010 Corrected, contact lenses and glasses Hearing: N/A EKG: N/A Chest X-ray: 2009 Negative TB Test: 1999 Negative Colonoscopy: N/A Stool Guiac: 08/2010 Negative Mammogram: 04/2009 Negative PAP Smear: 08/2010 Negative Prostate: N/A Allergies (Medications, foods, animals, environmental agents, contact substances): Allergy- Reaction- Treatment- Red Dye in Foods Nausea Phenergan Seasonal Allergies Zyrtec or Claratin Any type of aerosol spray Triggers an asthma attack Inhaler or Nebulizer Cigarette Smoke Triggers an asthma attack Inhaler or Nebulizer Current Medications (Include prescription, over the counter, & herbal supplements): Drug, Dose, Route: Frequency: Reason for Using Drug: Necon, 1/35mcg, PO Q A.M., continuously B/C, Hormone Replacement Therapy Prozac, 40mg, PO Q A.M. Treatment for Depression and Anxiety Flax Oil, 1000mg, PO Q A.M. Decreases inflammation of Arthritis Vitamin D, 1000 IU, PO Q A.M. Help with absorption of calcium Chromium Picolinate, 1000mcg, PO Q A.M. Metabolism of carbohydrates Calcium, 600mg, PO Q A.M. Prevention of low calcium levels CO Q-10, 100mg, PO Q A.M. Migraine Headache Prevention Cranberry Fruit 1500mg, PO Q A.M. Promote Urinary Health Acai, 1000mg, PO Q A.M.. Boost Metabolism Omefa-3 Fish Oil, Q A.M.. To decrease effects of Arthritis, 1200mg, PO Migraine Headaches, and Depression Albuterol Inhaler PRN Relief from Asthma Attack Xopenex Inhaler PRN Relief from Asthma Attack Albuterol Sol, 2.5mg PRN Relief from Asthma Attack Xopenex Sol, 1.25mg PRN Relief from Asthma Attack Hairston -4- II. FAMILY HISTORY Construct a Genogram and turn in with typed history. (Please see attached.) Heart Disease: No Hypertension: Yes Stroke: Yes Diabetes: No Blood Disorders: No Breast Cancer: No Cancer (other): Melanoma Sickle cell: Yes Arthritis: Yes Allergies: Yes Asthma: Yes Obesity: No Alcoholism: No Mental Illness: Yes Seizure Disorder: No Kidney Disease: Yes Tuberculosis: No Other: Migraine Headaches III. FUNCTIONAL ASSESSMENT (Including Activities of Daily Living) 1. Self Esteem, Self Concept: Education (last grade completed, other significant education/training): C.H. graduated from high school and has completed multiple education class at Lander University. Since then she has attended multiple seminars offered by Greenville County School District to enhance the classroom experience. Financial status (income adequate for lifestyle and/or health concerns): C.H. states that her family has an adequate income for their lifestyle but they must budget their money wisely. Each month, she and her husband try to save a set amount of money for emergencies and retirement. Value-belief system (religious practices that impact perception of health or health-seeking behaviors): C.H. grew up in a Christian home and continues to live the lifestyle of a Southern Baptist. As a Christian, she cannot think of any religious practices that impact her health status. Perceived personal strengths: C.H. states that some of her personal strengths include being a good listener, being empathic, working well with children, patience, positive attitude, and ability to admit mistakes and learn from those mistakes. Hairston -5- 2. Activity/Exercise: Description of a normal day: C.H. states she has no idea what a “normal” day is especially working in kindergarten. She states you must be very flexible and always expect the unexpected. On week days, she typically gets up around 6:00 am, gets ready for work (bathing, dressing, packing lunch, etc.), leaves for work around 7:15 am, spends the day at school teaching kindergarteners, arrives back at home around 3:30 pm, prepares dinner around 6:00 pm, prepares activities for the following day and then relaxes until time for bed. On the weekends, she catches up on things that were not done during the week, such as household chores, errands, and visits family. Independent or needs assistance with ADLs (feeding, food preparation, hygiene, bathing, dressing, toileting, mobility): C.H. is independent. She does not require assistance with ADLs including feeing, food preparation, hygiene, bathing, dressing, and mobility. Due to a recent fall, at times she does require assistance with mobility but this is expected to be complete resolved with the help of physical therapy, which she is currently attending. Hobbies/leisure time activities (type, time spent, benefits): C.H. states that her hobbies include reading, camping at the beach, spending time with her family, and watching the Tennessee Volunteers. C.H. explains that she spends as much time as she can doing these things, which recently she has discovered has not been much time at all. C.H. states the benefit of reading, camping, and spending time with her family allows her to relax, decompress, and make her very happy since they are all things she likes to do. Exercise Habits (type, time spent, frequency, warm-up, benefits): C.H. states that she does not have regular exercise habits but she hopes that after she fully recovers from the recent fall and as the weather warms up that she will be able to start walking daily for exercise. 3. Sleep Rest Patterns (Usual bedtime, hours of sleep, sleeping aids, naps, usual time arising, get up during night): C.H. states that she typically goes to bed around 10 p.m. When possible, she likes to get about nine hours of sleep, this is when she feels the most rested, however she typically only gets seven to eight hours of sleep. C.H. denies the use of any form of sleep aid. On workdays, C.H. states that she usually gets up around 6 a.m., but on weekends she likes to sleep in until about 8 a.m. She gets up one to two times during the night to use the restroom. 4. Nutrition: 24 hour Recall (type, amount, time eaten): Time: Food or Beverage Consumed (with amount): 7:00 am Cup of Coffee 7:30 am Cup of Coffee 8:00 am Chocolate Chip Bagel, Cup of Coffee 9:30 am Small cup of Root Beer, Daily Medications 11:30 am Snack of jelly beans, handful 1:00 pm Cashews, ½ cup, with a cup of Diet Pepsi 2:30 pm Cashews, ½ cup Hairston -6- 4:00 pm Peanut M &M’s, about 25 6:00 pm Two cups of Iced Tea 7:00 pm Cheeseburger and Fries, Diet Pepsi 8:00 pm Cup of tea, handful of jelly beans, handful of cashews Is this menu typical of most days? No, this is not a typical menu for C.H. This was on a Saturday. During the week, C.H. states she usually eats 3 meals (breakfast, small lunch, dinner) without snacks between them. Who buys food? C.H. Who prepares food? C.H. Finances adequate for food? Yes, must budget but adequate finances. Who is present at mealtime? C.H., Husband, Daughter Preferences/Dislikes/Intolerances: C.H. prefers to have home cooked southern meals. C.H. made a comment that everything is better fried, with potatoes and gravy, and bread on the side. C.H. dislikes fish and green vegetables but will tolerate them every now and then. C.H. denies having any intolerances. 5. Interpersonal Relationships: Others living in the home: Husband and Daughter Role in the family: C.H. feels that her role within the family is to keep the balance of schedules and maintain structure. Perception of relationships with family, friends, coworkers, classmates: C.H. has a positive perception of her relationship with family, friends, and classmates. Since the death of her brother, her relationship with her sister has not been very strong, however they are currently working to better their relationship. C.H. states she enjoys the company her coworkers provide. Get support from: Family, Friends, Coworkers; C.H. believes all of them are supportive of her decisions. Time spent alone? (Good or bad): C.H. states that she does enjoys time spent alone because it allows her to relax, enjoy the peace and quiet, think, and read. 6. Coping and Stress Management: Stresses in life now: C.H. states that she currently has multiple stressors in her life. In the fall, the school where she is currently employed will be getting a new principal and C.H. is concerned about the role of a new boss. Her husband’s company is also making changes and several employees have been cut; C.H. is worried that he may be cut from the company. Due to the possibility of her husband losing his job, C.H. is currently worrying about their financial situation since he is the main provider for the family. C.H. states she is worried about her aging parents and in- Hairston -7- laws. At this time, they can provide for themselves however C.H. can tell a decline in their health. Recent lifestyle changes: C.H. denies any recent lifestyle changes. Stress-reductions techniques utilized: C.H. is currently taking Prozac to help with stress and depression. C.H. enjoys spending time at the beach to reduce her stress, “likes to get away”. Reading and sleeping are also ways C.H. reduces her stress. 7. Personal Habits: Daily intake caffeine (coffee, tea, colas): C.H. states “caffeine is a must have”. Two cups (10oz) of coffee in the morning, Two-Six cups (16-48oz) of Soda or Tea throughout the day. Smoking: N/A Number of pack years___________Ever quit______________ Alcohol: N/A Number drinks per week__________Age started____________ Recreational (street drugs) used: N/A Perceived effect on social/work relationships: N/A 8. Environment Hazards: Housing and neighborhood (type of structure, live alone, know neighbors): C.H., her husband, and daughter live in a two-story home in Greenville County. This has been their residence for the last 15 years. All of their family, including parents, siblings, etc. lives within about a 5-mile radius. Safety of area: C.H. states she feels safe living in the area. Most of the people living around them are in their upper 60s and 70s. C.H. states that not much mischief occurs within their neighborhood. Adequate heat and utilities: C.H. states her family has adequate heat. They heat their home with a wood stove. For hot water, they have a gas furnace. They have adequate air conditioning in the summers, however they try to leave the air conditioning off as long as they can to conserve energy. Access to transportation/primary mode: C.H. has her own vehicle and driver’s license. C.H. considers herself to be a safe driver; however she avoids driving whenever possible. To work, C.H. is her own primary mode of transportation. To other events, errands, etc., C.H. prefers for her husband or daughter to drive. Hazards at workplace/school/home: C.H. denies any hazards in the workplace or at home. Hairston -8- Use of seatbelts/helmets: C.H. always uses her seatbelt. Travel/residence/military service in other countries: C.H. denies any travel out of the country. Hazards in home or workplace: C.H. denies any hazards in the workplace or at home. 9. Perception of Own Health: Definition of health: According to C.H., health is defined as the ability to participate in normal, everyday activities without a major illness or disease. Perception of health: C.H. perceives her currently health status to be fair. She states that her health benefit if she was not suffering from depression. C.H. also states she could lose some weight. Expectations/goals for the future: C.H. states her main goal regarding her health is to start exercising. Due to a recent fall, this goal has been delayed but as she continues to heal, she hopes to start exercising daily. She also hopes to get her husband to participate in exercise as she thinks he would benefit as well. C.H. knows she wants to start out with a small accomplishable goal so that she will continue to exercise and not give up easily. Expectation of health care providers: C.H. is currently happy with her health care providers. Her expectations include a HCP that will listen to the current situation. For C.H., a HCP that will take the time to listen is very important. C.H. states, “It is hard to find a doctor that will sit down and talk with you”. III. REVIEW OF SYSTEMS (Subjective data) Include both past health problems, even if resolved and current problems including date of onset. 1. General Overall Health State: C.H. is an overall healthy individual, currently experiencing pain from a recent fall and has mild sinus pressure and drainage due to seasonal allergies. C.H. denies recent weight change or change in sleep habits. C.H. states, “overall I feel pretty good”. 2. Integument (Skin, Hair, and Nails): Skin: C.H. denies history of eczema, psoriasis, and hives. In the past few years, C.H. has noticed spots of hyperpigmentation mainly on her face related to aging and sun exposure. C.H. has not noticed any changes in skin moisture, pruritus, nor excessive bruising. Hairston -9- Hair: C.H. denies any loss or increase of hair. She has noticed the texture of her hair has become more dry in the past few years. At the age of 35, C.H. discontinued the use of hair dyes and chemicals. Nails: C.H. denies change in color or shape of her nails but has noticed her nails becoming more brittle as she ages. C.H. states she is regularly in the sun, including lengthy summer stays at the beach, but does use sunscreen of at least SPF 15 and reapplies frequently. 3. Lymphatic: C.H. denies any lumps or swelling of the neck, infection, tenderness, pain, or edema. C.H. has not noticed any masses or lumps located throughout the lymphatic system nor does she have a history of lymphatic problems. 4. Head, Neck, Nose, Mouth, and Oropharynx: Head: C.H. states that she started having migraine headaches about two years ago. The migraine headaches differ in onset. Typically, the onset is very sudden with some type of auras prior but many times she does not realize she had the auras until after the migraine. The location of pain is all over her head and rarely is she able to pinpoint where the pain started. The character seems to be uniform with a throbbing sensation that she can feel throughout her body. The course and duration of the migraine headaches differ between episodes. Due to a family history of migraine headaches, C.H. states that her physician is working closely with her to help her determine any precipitating factors, how to decrease the duration, and coping mechanisms for the headaches. C.H. states that she has tried several different medication regimens to help decrease the frequency and severity of the headaches but at this time one has yet to be determined that works adequately. C.H. denies head injuries, syncope, and vertigo. Neck: At times C.H. does experience neck pain; mainly experienced at work when teaching kindergartners one-on-one due to leaning forward to assist students. The pain does not radiate and is relieved with over the counter NSAIDs. C.H. also believes some of the pain is stress induced. C.H. denies limited movement, masses, node enlargement, swelling, tenderness, and stiffness of the neck. Mouth and Oropharynx: C.H. is currently experiencing mouth pain (only when area is touched) due to recent oral surgery involving reconstruction of the maxilla. C.H. denies having a sore throat at this time. She has however had episodes of strep throat in the past; about 1-2 times per year. Gums are typically healthy and do not bleed. C.H. currently experiences tooth pain associated with the recent oral surgery. C.H. does not have temperature-sensitive teeth. C.H. had not lost any teeth prior to maxilla reconstruction. Due to surgery however, the upper right canine and upper right first premolar were removed but replaced temporarily with a dental appliance. C.H. denies any mouth sores or lesions. C.H. denies any difficulty swallowing, chewing, or speaking. C.H. still has her tonsils and has not noticed a change in taste. C.H. brushes her teeth and flosses regularly. She also rinses with a fluoride mouthwash. Her last dental exam was in March 2011. Hairston - 10 - Nose and Sinuses: C.H. denies any regular or recurring nasal discharge. Due to history of asthma, C.H. usually suffers from at least one upper respiratory infection per year. C.H. states sinus pain and tenderness only occur with seasonal changes due to allergies. To lessen the severity of these symptoms, C.H. takes Zyrtec as needed. C.H. denies nasal obstruction, change in sense of smell, snoring, and post-nasal drip. As a child, C.H. states she experienced nosebleeds but has not had one in many years. 5. Ears: C.H. denies earache, infection, and discharge. Pt. believes she is starting to have some hearing loss but believes it is related to aging, has not noticed it affecting her daily activities. C.H. states she cleans her ears every night and she knows she inserts the cotton swab too far into her ear. C.H. denies tinnitus, vertigo, and does not use a hearing aid. 6. Eyes: C.H. denies any difficulty with vision including blurring and blind spots. No halos noted around objects per pt. C.H. states that she does have difficulty seeing at dusk and tries to avoid driving at this time of the day. C.H. states no pain of the eye, strabismus, redness, swelling, discharge, cataracts, and glaucoma. C.H. alternates between wearing glasses and contact lenses. Pt. states last eye exam was about a year ago and did not have a prescription change at that time. No problems reported with contact lenses. C.H. states she takes her contacts out every night as directed. 7. Respiratory: C.H. denies any regular cough, shortness of breath, wheezing, chest pain with breathing, or night sweats. C.H. was diagnosed with adult onset asthma about 10 years ago. During an acute asthma attacks pt. does have shortness of breath and wheezing. Aerosol sprays and cigarette smoke are two main triggers for an asthma attack. C.H. has a history of bronchitis and pneumonia related to asthma. C.H. last experienced bronchitis in January 2011. Her last asthma attack was November 2010 and was relieved by a steroidal inhaler. Her rescue inhalers consist of Xopenex and Albuterol. For more severe cases, C.H. makes use of a home nebulizer with Xopenex and Albuterol inhalation solution. 8. Breast and Axillae: Breast: C.H. denies any breast pain, change in size, tenderness, discharge, dimpling, or rash. Many years ago C.H. experienced a lump in her right breast. After further investigation, it was determined to be an infected milk duct. C.H. denies any lumps at this time. Axillae: C.H. denies tenderness, lumps, swelling, or rash. Self-Breast Exam: C.H. last performed a self-breast exam in March 2011 and does so regularly at the beginning of each month. C.H. has yearly mammograms. Hairston - 11 - 9. Cardiovascular: C.H. denies having any chest pain or palpitations at any point in time. C.H. does not experience any shortness of breath due to chest pain – only during above-mentioned asthma attacks. C.H. has never noticed any cyanosis or discoloring of the face or lips. C.H. denies experiencing swelling, edema, nocturia, or hypertension. She does not have a pacemaker. 10. Peripheral Vascular: C.H. denies having any coldness, numbness, or tingling in her extremities. C.H. sometimes experiences leg pains and cramps mainly at night; which are relieved by walking. C.H. has not noticed any changes in her skin color or temperature. C.H. states she has not experienced any peripheral edema in arms or legs, nor does she report any swollen glands or lymph nodes. C.H. has not noticed any varicose veins. 11. Gastrointestinal: C.H. states that she has not had any recent changes in appetite or weight. Due to bowel resection in 1992, C.H. states that she cannot eat foods that contain hulls, such as corn and blueberries, because her body is not able to digest them. C.H. denies any dysphagia, heart burn, indigestion, hemastasis, belching, and use of antacids. C.H. also denies any chronic nausea or vomiting. At this time, C.H. does not complain of any abdominal pain, however prior to appendectomy in 1991, C.H. states she was having severe LRQ pain. Pain continued throughout exploratory surgery. C.H. explains that she experiences regular, daily bowel movements. Since bowel resection, C.H. has looser stool. C.H. denies constipation, use of laxatives, and rectal problems. 12. Musculoskeletal: C.H. reports that at times she experiences some pain in her hands, due to diagnosed osteoarthritis. Pain usually occurs in the winter and is relieved with heat. C.H. has not noticed pain affecting her ADLs. C.H. recently experienced a fall down two steps landing on a cement floor. She reports having damaged tendons and ligaments in both ankles. She only reports pain, swelling, and stiffness due to her recent injuries, which are currently being treated with physical therapy. C.H. denies any other joint pain, swelling, or tenderness. C.H. states she has limited range of motion in both ankles due to recent fall. She is able to walk and is expected to fully recover after physical therapy is completed. C.H. denies any crepitus, muscle weakness, bone pain, or deformities of bones and joints. 13. Neurologic: C.H. has no history of seizures, strokes, fainting, convulsions, head injury, dizziness, vertigo, ticks, tremors, spasms, numbness, tingling, incoordination, or ataxia nor does she currently experience these conditions. C.H. does experience migraine headaches as detailed in the above section on the head. Hairston - 12 - 14. Mental status: C.H. denies nervousness but does experience anxiety in certain situations i.e. dental visits and unknown situations. C.H. is oriented to person, place, and time. She denies having problems with memory, speech, perception, thinking, attention span, decision-making, and calculations. C.H. suffers from depression with onset after the death of her sibling in 2006. She denies suicidal ideations. 15. Urinary: Currently, C.H. denies any abnormalities with urination. She states that she does have a history of UTIs with pain and burning while urinating. C.H. awakens 1-2 times during the night to urinate. C.H. denies any change in urine color, odor, or amount and denies narrowed stream, incontinence, or having any back, flank, or groin pain. 16. Male Genital: N/A 17. Female Genital: C.H. states that her last menstrual period was approximately two years ago. Her doctor has continued her regimen of birth control to regulate hormones to aid in the reduction of migraine headaches. She states age of menarche was 15 with menstrual cycle lasting about 27 days and duration of menstrual period of 5 days. At times C.H. would experience dysmenorrhea. C.H. states she has not yet experienced any menopausal symptoms including hot flashes, palpitations, or mood swings. C.H. also denies vaginal discharge, itching, rash, dyspareunia, postcoital bleeding, or pain. 18. Hematologic: C.H. denies any issues with excessive bleeding, easy bruising, nor does she have any clotting issues. C.H. also denies having any blood transfusions or chronic swollen lymph nodes. 19. Endocrine: C.H. denies any diabetes or diabetic symptoms, thyroid disease, intolerance to heat/cold, changes in skin pigmentation or texture, excessive sweating, or having changes in appetite or weight. C.H. does not complain of nervousness, weakness, hair loss or distribution, or changes in breast size. She explains a recent blood panel revealed normal thyroid function and values were within normal range. Hairston - 13 - ASSESSMENT FINDINGS: Document a COMPLETE PHYSICAL ASSESSMENT using the Jarvis (5th edition) Complete Physical Examination Form as a guide. 1. General survey and vital signs (don’t need to do vision assessment). 2. Skin 3. Head and face 4. Eyes, ears, nose, mouth, and throat 5. Neck 6. Chest and lungs 7. Breasts 8. Abdomen 9. Inguinal area 10. Musculoskeletal – upper and lower extremities 11. Neurologic **You do NOT need to do male or female genitalia or rectal exams** (Please see attached.) ANALYSIS: 1. What is the primary medical diagnosis (if any) for the patient? There is no primary medical diagnosis for C.H. Pt. suffers from occasional migraine headaches and asthma. 2. How do the assessment and history findings support the medical diagnosis? Most history and assessment findings are normal with exceptions due to recent injury and age. 3. Develop three priority nursing diagnoses for the patient, including goals and evaluative criteria. Anxiety R/T upcoming changes in the work environment - new principal and possible change in employment status - AEB pt. statement “One of my main stressors, causing me to be very anxious, in my life right now is that my boss (principal) is retiring and we are not sure who will fill his place and what changes will be made.” Goal: The pt. will experience a reduction in anxiety AEB verbalization of feeling less anxious and stressed. Evaluative Criteria: Did the pt. verbalize feelings of anxiety to family members, a professional therapist, or co-workers? Did the verbalization to the above parties reduce or increase anxiety? Will pt. continue to use the verbalization techniques to reduce anxiety in future situations? Hairston - 14 - Risk for Infection R/T recent (3/2011- Maxilla Reconstruction) oral surgery involving open wounds in the gum and removal of two teeth. Goal: The pt. will remain free of infection AEB absence of heat, pain, redness, swelling, and unusual discharge from the surgical site on the gum. Evaluative Criteria: Did the pt. experience any heat, pain, redness, swelling, or unusual discharge from the gum? Did the pt. take prophylactic antibiotics as prescribed? Is the pt. compliant with follow-up visits? Impaired Physical Mobility R/T recent fall (3/2011) with injury to left elbow and both ankles AEB patient’s hesitation to complete tasks required for head to toe physical assessment. Goal: The patient will achieve maximum physical mobility without the use of elbow compression and ankle braces. Evaluative Criteria: Did pt. continue physical therapy session as suggested by orthopedists? Was the pt. able to complete ROM of affected extremities without hesitation once injuries healed? Is pt. psychologically able to perform certain mobility tasks (such as walking up stairs, driving long distances, or exercising) without hesitation after physical healing has occurred?
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