Adult Health History and Examination Essay Sample
Neurological System concerns. caput hurts. giddiness. paroxysms. shudders. failing. numbness. prickling. trouble speech production. and trouble get downing etc. . medicine ) : Neurologically JP is integral. Alert ox3 clear address with no vacillations. c/o concerns and giddiness on occasion. upon originating in the am. She admits being “little stressed to household situations” and revolving displacements ( DAYS/NIGHTS ) . Suggested to seek EAP ( Employee Assistance Program ) at work Head and Neck ( hurting. concerns. head/neck hurt. cervix hurting. lumps/swelling. surgeries on head/neck. medicines: LH has full ROM to make out and caput. closes her eyes and able to keep her weaponries and hands out without rocking. LH takes Motrin 800mg for concerns. Motrin ( isobutylphenyl propionic acid ) is a no steroidal anti-inflammatory drug ( NSAID ) . It works by cut downing endocrines that cause redness and hurting in the organic structure. This medical specialty may besides do serious effects on the tummy or bowels. including shed blooding or perforation ( forming of a hole ) .
These conditions can be fatal and can happen without warning while you are taking Motrin. particularly in older grownups. Nursing Drug Handbook ( 2013 ) Eyes ( oculus hurting. blurred vision. history of crossed eyes. redness/swelling in eyes. irrigating. rupturing. injury/surgery to oculus. glaucoma proving. vision trial. spectacless or contacts. medicines: LH has myopia and astigmia. She wears spectacless for rectification and contact lenses for aesthetics. no familial history of glaucoma. last oculus test on Sept 12. with no jobs. Ears ( otalgia or other ear hurting. history of ear infections. discharge from ears. history of surgery. trouble hearing. environmental noise exposure. dizziness. medicines: LH states “better than norm. ” “I can’t see. but I sure can hear” . Denies tinnutitis. or being subjected to loud noises. She has had no surgeries or infections. Nose. Mouth. and Throat ( discharge. sores or lesions. hurting. epistaxiss. shed blooding gums. sore pharynx. allergic reactions. surgeries. usual dental attention. medicines: LH joke physiological reaction integral. unwritten mucosa moist. tap integral.
Teeth intact. pits noted on 2 back dentition. last dental test was Jan2012. with a pit filled. discussed the demand to floss more. she brushes daily and after repasts. Reports frequent rhinorrhea and rhinal congestion. during the spring and summer. She self-treats this with over the antagonistic Claritin-D 10/200mg LH feels that she has seasonal allergic reactions. she refuses allergy proving. LH provinces “I do non necessitate to be poked to cognize I have hay fever” . Reinforced to LH the drug categorization and side effects of Claritin D. The decongestant in Claritin-D is Pseudoephedrine sulphate. which is the man-made salt of one of the of course happening dextrorotatory. diastereomers of ephedrine. It is classified as an indirect adrenergic aminoalkane. and is in the amphetamine category. Nursing Drug Handbook ( 2013 ) The American Dental Association recommends that grownups brush their dentitions two times a twenty-four hours. Research has shown that infections in the oral cavity may be associated with bosom disease. shot. diabetes. pneumonia and other wellness jobs that are common in older grownups ( American Dental Association. 2012 )
Skin. Hair and Nails ( skin disease. alterations in colour. alterations in a mole. inordinate waterlessness or wet. itchiness. bruising. and roseola or lesions. recent hair loss. altering nails. environmental hazards/exposures. medicines ) : LH has soft. lissome warm tegument. LH has old acne marking over facial country stated “I had truly bad hickeies when I was younger and used to picked them. but I have non had any issues in years” . LH besides has thinning hair “I have had had it for years” . Maternal History of Alopecia and thinning hair. LH female parent started losing hair in teens. LH uses Rogaine shampoo 3 times a hebdomad. Women see more dramatic. localized hair thinning. even a noticeable bald topographic point. This status is called male form phalacrosis. or androgenous alopecia ( AGA ) . and it is the most common signifier of hair loss in both work forces and adult females. It about ever occurs on the top and sides of the caput and above the brow. and may besides affect inordinate hair growing on the face and other countries on the organic structure. though the scope of badness is broad. WebMD. com. Rogaine dilates blood vass in the scalp. which may better hair follicle map and stimulate hair growing.
Rogaine is used to handle male pattern phalacrosis in patients who are sing bit by bit thinning hair on the top of the caput. World Wide Web. drugs. com Breasts and Axilla ( hurting or tenderness. balls. nipple discharge. roseola. swelling. injury or hurt to breast. mammography. breast self-exam. medicines ) : LH denies implants. injury or hurt LH stated “I would love saline implants. I breast fed both of my kids “She performs self-breast tests in the shower monthly. and her physician test her annual for her physical. Her last mammogram was April 2012. Mammogram is a low-dose x-ray test of the chests to look for alterations that are non normal. The consequences are recorded on x-ray movie or straight into a computing machine for a physician called a radiotherapist to analyze. Womenshealth. gov Peripheral Vascular and Lymphatic System ( leg hurting. spasms. and skin alterations in weaponries or legs. swelling in legs or mortise joints. conceited secretory organs. medicines ) : LH studies that she does non hold leg spasms or hurting. but that she does hold “varicose veins” .
LH denies usage of compaction hosiery. Promote to utilize compaction hosiery. when standing and sitting for long periods. Cardiovascular System ( chest hurting or stringency. SOB. cough. swelling of pess or custodies. household history of cardiac disease. tyre easy. self-history of bosom disease. medicines ) : LH denies shortness of breath. weariness or puffiness of appendages. LH has a maternal and paternal history of high blood pressure. LH understands the branchings of familial history of high blood force per unit area. Denies chest hurting. Hypertension occurs when the blood force per unit area. or force of blood forcing against the blood vas walls. gets excessively high and corsets that manner. It occurs most frequently in African-Americans. The top figure. or systolic blood force per unit area. occurs when the bosom pumps or contracts. The bottom figure. or diastolic blood force per unit area. occurs when the bosom is resting or loosen uping. Most wellness professionals agree that the upper scope of normal blood force per unit area should be 130/80 or less. World Wide Web. Center for Disease Control and Prevention. gov Thorax and Lungs ( cough. SOB. hurting on inspiration or termination. chest hurting with external respiration. history of lung disease. smoking history. living/working conditions that affect take a breathing. last TB skin trial. grippe shooting. pneumococcal vaccinum. chest x-ray. medicines ) : LH denies COPD. asthma. bronchitis. No history of smoke.
Last TB trial was October 2012 for occupation annually testing. Musculoskeletal System ( joint hurting ; stiffness ; swelling. heat. inflammation in articulations ; restriction of motion ; musculus hurting or cramping ; malformation of bone or articulation ; accidents or injury to castanetss ; back hurting ; trouble with activity of day-to-day life. medicines ) : LH had a right articulatio genus arthroscopy on January 11. 2013. She has been ramble oning 3x hebdomadal for the past 18 old ages. The articulatio genus surgery was for normal wear and rupture due to running on difficult surfaces. LH has full read-only memory on left appendage. LH is presently taking Nucynta 50mg for hurting alleviation. Tapentadol ( trade names: Nucynta ) is a centrally moving analgetic with a double manner of action as an agonist of the ?-opioid receptor and as a norepinephrine re-uptake inhibitor. It is besides an agonist of the ?2 receptor. though the map of this orphan receptor remains controversial. While its analgetic actions have been compared to tramadol and oxycodone. its general authority is someplace between tramadol and morphia in effectivity.
It has opioid and nonopioid activity in a individual compound. Nursing Drug Handbook ( 2013 ) . Knee arthroscopy is a minimally invasive surgical process in which an scrutiny and sometimes intervention of harm of the inside of a joint is performed utilizing an arthroscopy. a type of endoscopy that is inserted into the joint through a little scratch. Arthroscopic processs can be performed either to measure or to handle many orthopaedic conditions including lacerate floating gristle. lacerate surface gristle. ACL Reconstruction. and paring damaged gristle. Gastrointestinal System ( alteration in appetite – addition or loss ; trouble swallowing ; nutrients non tolerated ; abdominal hurting ; sickness or emesis ; frequence of BM ; history of GI disease. ulcers. and medicines ) : LH denies any issues of digestion ; she eats 2 full repasts daily ( breakfast and dinner ) and bites between. largely fruits and nuts. LH is 67 inches and 148 pound. Genitourinary System ( recent alteration. frequence. urgency. nycturia. dysuria. polyuria. oliguria. hesitance or straining. urine colour. narrowed watercourse. incontinency. history of urinary disease. hurting in wing. inguen. suprapubic part or low back ) : LH denies any urinary frequence. dysuria or polyuria at this clip. Physical Examination
( Comprehensive scrutiny of each system. Record findings. ) Neurological System ( test of all 12 cranial nervousnesss. motor and centripetal appraisals ) : Luteinizing hormone is able to smile. smirk and wink without trouble. Her face is symmetrical with no nonvoluntary motions ( i. e. jerking ) . She able to place odors and gustatory sensation without trouble. All cranial nervousnesss are integral.
Head and Neck ( feel the skull. inspect the cervix. inspect the face. feel the lymph nodes. feel the windpipe. palpate and auscultate windpipe and thyroid secretory organ ) : Trachea is clear. thyroid is midline integral. Lymph nodes are little and non-visible LH’s caput is circular and is normocephalic. with no tenderness upon tactual exploration. She has dry thinning hair. Eyes ( test ocular sharp-sightedness. ocular Fieldss. excess optic musculus map. inspects external oculus constructions. inspect anterior orb constructions. inspect optic fundus ) : Luteinizing hormone has symmetrical black. thinning superciliums. with evenly topographic point dark brown eyes that appear level. Her sclerotic coat are white and moist. her students are PERRLA 3mm. Both conjunctivae are pink. and no ulcers are noted. There is a positive corneal physiological reaction noted. She is able read a Snelling oculus chart top line with her spectacless on. and so she can read the smallest line. No nystagmus noted. Ears ( inspect external construction. otoscopic scrutiny. inspect tympanic membrane. and trial hearing sharp-sightedness ) : her ear lobes are symmetrical. bean shaped.
The pinnule recoils. Small metal balls noted in lobes. Auricles are holding a steadfast gristle on tactual exploration. with no tenderness. No discharge noted. with little chocolate-brown ruddy earwaxs noted in left ear. the membrane is level. and pearly grey in colour Nose. Mouth. and Throat ( Inspect and feel the olfactory organ. palpates the sinus country. inspect the oral cavity. inspect the pharynx ) : LHs olfactory organ is midline without discharge. The rhinal septum is midline. The rhinal mucous membrane is ruddy pink. Both nares are patent. The frontal and maxillary sinusitis is integral no tenderness upon tactual exploration. No Temporomandibular crepitus noted. Chewing gums are pinkish. without shed blooding. Withdrawing gums noted on lower forepart dentitions. Dental carries in back dentition and no halitosis. Tongue pink moist intact has no lesions or varicosities. JP is able to travel her lingua freely. Gag physiological reaction is integral. Her tonsils were removed at age 4. Her windpipe is midline. with no nodules. Her thyroid is non tangible. She has scope of full gesture in her cervix. Skin. Hair and Nails ( inspect and palpate tegument. temperature. wet. lesions. inspect and palpate hair. distribution. texture. inspect and palpate nails. contour. colour. learn introspection techniques ) : Skin colour is brown. supple and warm. There is a midline cicatrix noted on lower venters. good healed and integral. Nails manicured. pink with Polish in topographic point. Breasts and Axilla ( deferred )
Peripheral Vascular and Lymphatic System ( inspect weaponries. symmetricalness. pulsations ; inspect legs. venous form. varicosities. pulsations. colour. swelling. and balls ) : LH legs are warm. integral. green broken venas noted on the dorsum of both legs. integral. Radial pulsations are tangible. strong. and equal. Roentgen 56. L58Her legs show no venous engorgement. Bilateral pedal pulses 2+ . strong. Cardiovascular System ( inspect and palpate carotid arterias. jugular venous system. precordium heaving or lift. apical urge ; auscultate rate and beat ; place S1 and S2. any excess bosom sounds. mutter ) : No jugular vena dilatation. No lift. heave. or pulsing over the aortal. pneumonic. or mitral valves. Heart sounds are strong and regular. with S1S2 hearable at all anatomic sites.
Apical rate 58 Sinus Bradycardia no ectopy. jugular venas distention noted. Thorax and Lungs ( inspect thoracic coop. symmetricalness. haptic fremitus. windpipe ; feel symmetrical enlargement ; percussion of anterior. sidelong and posterior. unnatural take a breathing sounds ) : Lung sounds clear bilaterally throughout lung Fieldss Musculoskeletal System ( inspect cervical spinal column for size. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect shoulders for size. colour. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect cubituss for size. colour. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect carpus and custodies for size. colour. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect hips for size. colour. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect articulatio genuss for size. colour. contour. swelling. mass. malformation. hurting. scope of gesture ; inspect mortise joints and pess for size. colour. contour. swelling. mass. malformation. hurting and scope of gesture ) : Extremities are equal in size. with equal contraction. and no nonvoluntary motions.
LH is able to counter act gravitation and opposition on ROM. Reflexes integral and strong. All appendages can execute full scope of gesture. There is no hydrops and no crepitus. Extremity colour is even. Gastrointestinal System ( contour of venters. general symmetricalness. skin colour and status. pulsing and motion. navel. hair distribution ; auscultate intestine sound ; . percuss all four quarter-circles ; percuss boundary line of liver ; light tactual exploration in all four quadrants– musculus wall. tenderness. hypertrophied variety meats. multitudes. bounce tenderness. CVA tenderness ) : Contour is level with no seeable vermiculation. Skin is pink with striae noted on lower abdominal quarter-circles. No aortal pulsing noted. No tenderness. with intestine sound noted in all 4 quarter-circles underactive. Abdomen soft and level. The liver can non be palpated. Tension is smooth and consistent with no musculus guarding. Genitourinary System ( deferred )
Cognitive-Perceptual Form: LH wears spectacless for disciplinary vision. has long term and short term callback. Learns best by listening. she is able to hear and compose without trouble. LH is frequently distracted by place state of affairss and emphasis. LH is sing uncomfortableness for her right articulatio genus. she utilizing heat battalions and hurting medicine. Nutritional-Metabolic Form: Luteinizing hormone watches her Na. fat and sugar consumption. She is non dieting ; nevertheless her end is to keep her weight within 5lbs of the mark Harmonizing to the American Heart Association 2012. cholesterin is governable. and a major factor in hazard for coronary arteria disease. shot. and bosom onslaught ( AHA. 2012 ) . Sexuality-Reproductive Form: LH is Gravida 2. Para 2 Abortions 0. She has 2 grownup boies. and 1 grandson. LH is premenopausal and denies complications except for the occasional “hot flash” . LH is non utilizing any medicines “I’m allowing it happen naturally” . LH is married this is her 3rd hubby. been married for 8 old ages and is sexually active and monogamous.
Pattern of Elimination: LH studies daily bowel motions. with occasional irregularity. She uses prune juice and Metamucil. Pattern of Activity and Exercise: LH was running 3x hebdomadal until the process she is presently making Physical Therapy 2x hebdomad for 6 hebdomads. She lifts manus weights daily. Pattern of Sleep and Rest: LH sleeps 5-6 hours daily without sleep AIDSs. Pattern of Self-Perception and Self-Concept: LH is seting to her function as charge nurse at dark. keeping her function as married woman. grandma and female parent. LH has 1 brother. who she speaks to weekly and her female parent 3x weekly. Both of whom lives in another province. LH states “I experience better than most adult females my age” Situation ( ground for seeking attention. patient statements ) : LH is a 47 year-old African American female. She is 67 inches and 149lbs. She is position postop right articulatio genus arthroscopy Right articulatio genus uncomfortableness. right articulatio genus with one dressing.
LH uncomfortableness degree is 4/10. pounding when up ambulating. Background ( wellness and household history. recent observations ) : The patient has a history of right articulatio genus hurting after ramble oning Assessment ( appraisal of wellness province or jobs. nursing diagnosing ) : VSS= T 36. 1. P58. BP 106/58. Patient faces upon walking. Gait steady. ambulating with crutches full weight bearing on right articulatio genus. No Pedal pulses +2. habitue. Students are PERRLA. Lung sounds are clear bilaterally throughout lung Fieldss and bosom rate is regular 58 SB with S1S2 hearable. Recommendation ( diagnostic rating. follow-up attention. patient instruction learning including wellness publicity instruction ) : instruction on hurting direction. manus rinsing and exercising. Continue with Physical therapy Patient instruction on the usage of anti-thrombotic hosiery. when standing and walking for long periods. Stretching musculuss prior to exerting. Stretching the musculuss and sinews that surround the articulations to better flexibleness.
Nursing Diagnosis: Impaired Physical Mobility R/T to diminish ROM of right articulatio genus 1 hebdomad station op. Intervention 1: Educate LH to halt running on difficult surfaces or activity instantly and describe to the doctor if she experiences the undermentioned symptoms: new or worsened strength or increased frequence of discomfort Rationale: Runing on difficult surfaces causes. the articulations and sinews to go worn and loses the synovial fluid around the joint. Patient Result: LH will hold less uncomfortableness when running.
Intervention 2: LH will go on with physical therapy for opposition exercising preparation. including abdominal crunch. leg imperativeness. leg extension. leg coil. calf imperativenesss. Rationale: Six months of opposition exercising greatly increased their aerophilic capacity. perchance from increased skeletal musculus strength and flexibleness. Decision
LH has healthy behaviours sing physical wellness. However. she needs to develop better ways to alleviate emphasis. ( i. e. talking with a counsellor. reading books. go toing church ) . Besides LH needs to better her sleeping hours. by developing sleep clip rites ( i. e. turn off Television. turn off visible radiations. and cover the Windowss ) . LH will pull off her uncomfortableness. by go oning on hurting medicine as prescribed. and follow up with sawbones assignments as directed. Suggested LH utilize local YMCA for H2O exercising. less tenseness on the articulatio genuss. LH will be go toing church and bible survey to assist with get bying mechanisms.
Carpenito L. J. ( 2011 ) . Nursing Diagnosis Handbook: An Evidence-Based Guide to
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