PAST MEDICAL HISTORY.

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Running Head: DISCUSSION WEEK 14

 

 

 

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Running Head: DISCUSSION WEEK 14

 

 

 

 

Discussion Week 14

Physical Assessment in Healthcare

Daylamis Gonzalez

Florida National University

 

 

 

 

 

 

 

 

 

 

 

 

Name: Jessica Date 11/28/2017

DOB: 11/11/1985 Tine 11:47 AM

Age 32 Sexo Female

Address 1245 west 47 st Hialeah Florida 33012 Ethics Hispanic

Nationality Cuban Occupation Math teacher

Allergies NDKA

Marital status

What is your highest education? Bachelor’s degree in mathematics and a master’s degree in education

Medications that you are now taking No

 

PAST MEDICAL HISTORY

Paralysis No

Smoking Quit smoking 10 years ago (two packs daily for 5 years)

Alcohol Occasional wine cooler

Previous Surgery Tonsillectomy/adenoidectomy at age 11

Chronic Health Condition No

Children 4

C-section No Vaginal Delivers 4 Abortions No

Epilepsy No Stroke No Chickenpox Yes Rubella No

Asthma No Lupus No Cancer No Diabetes No Cardiac Disease No

Kidney Disease No Hemophilia No Hypertension No GI Disease No

Herpes No HIV No Syphilis No Hepatitis No

If any of the answers is yes, explain: chickenpox at age 10

FAMILY HISTORY

Mother Hypertension

Father Coronary artery disease (he had a stent placed at age 67)

EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT:

Maternal relatives N/A

Paternal relatives N/A

Assessment

BP 135/85 mm/Hg HR 64 BPM Temp 98.5°F Resp 16 breath for min Pain 0

Nursing Note

Patient come to Emergency department with a friend for evaluation of sudden decrease of vision in the left eye. She denies any trauma or injury. It started this morning when she woke up and has progressively worsened over the past few hours. She had some blurring of her vision 1 month ago and thinks that may have been related to getting overheated, since it improved when she was able to get in a cool, air-conditioned environment. She has some pain if she tries to move her eye, but none when she just rests. She is also unable to determine colors. She denies tearing or redness or exposure to any chemicals. Nothing has made it better or worse.

Upon assessment, Patient AAOx3, hemodynamic stable. Patient able to answer all question. Afebrile. Resp. even and unlabored. No respiratory distress noted. Patient denies fever, chills, night sweats, weight loss, fatigue, headache, changes in hearing, sore throat, nasal or sinus congestion, neck pain or stiffness, chest pain or palpitations, shortness of breath or cough, abdominal pain, diarrhea, constipation, dysuria, vaginal discharge, swelling in the legs, polyuria, polydipsia, and polyphagia. Bowel sound present in 4 quadrants. Visual acuity 20/200 in the left eye and 20/30 in the right eye. Sclera white, conjunctivae clear. Unable to assess visual fields in the left side; visual fields on the right eye are intact. Pupil response to light is diminished in the left eye and brisk in the right eye. The optic disc is swollen. Full range of motions; no swelling or deformity. Cranial nerves: I-XII intact; horizontal nystagmus is present. Muscles with normal bulk and tone; Normal finger to nose, negative Romberg. Intact to temperature, vibration, and two-point discrimination in upper and lower extremities. Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achiles tendons; no Babinski.

NURSING DIAGNOSIS

Risk for injuries due to impaired vision

Risk factor: falls

Desired outcome: Maintain safety without falls

Nursing Intervention: Environmental management

Teaching:

· Instruct patient to avoid rug

· Use appropriate lighting

· Orient patient to unfamiliar environment

Fear and Anxiety relate to visual impairment

Risk factor: lost vision

Desired outcome: Patient verbalizes feeling.

Nursing Intervention: Assess the patient’s fear related to feel depended.

Allow patients to verbalize feelings regarding recurrent visual problem,

Teaching:

· Teach patient how to manage anxiety, fear and stress

· Instruct patient to follow MD instruction as order

 

Pain

Risk Factor: Uncontrolled Pain

Desired outcome: Maintain pain controlled

Nursing Intervention: Assess patient pain level and take medication around the clock.

 

 

 

 

 

Bibliography Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s Guide to Physical Examination (8th ed.). St. Louis, MO: Elsevier/Mosby.

 

http://medicinebtg.com/nanda-nursing-diagnosis-for-vision-impairment/

http://allnurses.com/general-nursing-student/looking-for-nursing-185929.html

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PAST MEDICAL HISTORY

 

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