Nursing Process – SAMPLE Nursing Diagnosis
NANDA (North American Nursing Diagnosis)
Chronic Painrelated to unknown etiology
as evidenced by self-reports of pain “I feel pain when sitting or lying down mostly at night” using a standardized pain scale, 4/10 on a 0 to 10 numeric rating scale. The patient reports an altered sleep-wake cycle.
Patient Goal/Outcome
Interventions
Rationale for Interventions
Evaluation of Each Goal/Intervention
1)The Patient’s pain will reduce and her sleep will promote by using nonpharmacological methods such as supplements or enhance pharmacological interventions within the next three months.
1a) RN will in addition to administering analgesics, support the client's use of nonpharmacological methods to help
control pain, such as distraction, imagery, relaxation, and application of heat and cold.
1b) RN will ask the client to describe prior experiences with pain, effectiveness of pain management interventions,
responses to analgesic medications (including occurrence of side effects), and concerns about pain and
its treatment (e.g., fear about addiction, worries, anxiety) and informational needs.
1a) Evidence
suggested efficacy and satisfaction when complementary therapies are integrated into pain treatment plans of
older adults (Bruckenthal, 2016 as cited in Ackley et al., 2022, p. 723).
1b) Sleep disturbance and decreased physical activity are adverse
effects of people with chronic pain. In a study of clients with chronic pain, those who participated in a 4 week
multiprofessional program that included psychoeducation and training related to pain, sleep, exercise, and
activity training had improvement in sleep quality and pain intensity (de la Vega, 2019, as cited in Ackley et al., 2022, p. 721).
1a) Goal partially met. Patient’s pain decreased to level 2/10, with relaxation therapy such as meditation and usage of heat pads.
1b) Goal met. Patients starts to drink Valerian root tea and states “It reduced the amount of time takes me to fall asleep and helped me sleep better.”
Health history assignment part 1
Section 1: Biographic Data
N.V is a 46-year-old married Iranian woman, who currently is a full-time financial manager at BMW company. She speaks fluent English and does not require an interpreter.
Section 2: Source of History
The patient provides the information herself. The patient seems reliable, as she is alert and oriented.
Section 3: Reason for Seeking Care
The patient states, “I am really exhausted and want to get rid of my leg pain. I have severe pain in my thighs and legs and it started six years ago.”
Section 4: History of Present Illness (HPI)
The patient’s thigh and leg pain began six years prior to the interview. Her pain started following the birth of her second child. The patient has frequent episodes, the last being three days ago. It has never been resolved. It is specially located in the thighs and .
1[Shortened Title up to 50 Characters]2Week 9 Assignment.docxhallettfaustina
1
[Shortened Title up to 50 Characters] 2Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days du ...
1[Shortened Title up to 50 Characters]16Week 9 Assignment.docxhallettfaustina
1
[Shortened Title up to 50 Characters] 16Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days d ...
SubjectiveChief complaint headaches and blurriness of visi.docxpicklesvalery
Subjective:
Chief complaint: headaches and blurriness of vision on the right side
History of present illness: the patient is 67 years old Caucasian female, she complains of having had headaches for 2 weeks now. The pain is located in the right temporal area. She describes the pain as 8-10/10, sharp, constant, interferes with her sleep, she states that nothing aggravates it, not even the bright lights or high sounds, but she gets a little relief by taking Ibuprofen 800 mg. She stated that she has been having some blurriness in the right eye, while her left eye is fine. She also complains of pain in her jaw and tongue while chewing food. Her appetite has been low, and lost about 5 pounds in the last 2 weeks. She noticed low grade fever as well. She also reported ringing sounds in the right ear. She denies any nausea or vomiting. She denied having similar headaches in the past. The patient denies complaining of nasal or postnasal drainage.
PMH: past medical history is significant for Hypertension, type II diabetes mellitus, asthma, and degenerative arthritis of the knees.
PSH: hysterectomy
Medications: Lisinopril 10 mg PO QD
Metformin 500 mg PO BID.
Proair HFA 2 puffs PRN.
Ibuprofen 800 mg TID
Multivitamins
By comparing the medications that the patient is taking with Beers criteria, they all looked appropriate to be used in elderly patients.
Family Hx:
Father: HTN, diabetes, and stroke.
Mother: HTN, Diabetes, and breast cancer at the age of 72.
Social Hx: the patient never smoked tobacco products.
ETOH: social drinker
Illicit substances: denies ever using illicit drugs.
Allergies: penicillin.
Review of systems:
Constitutional: the patient complains of fever, fatigue, anorexia, and weight loss.
Head: the patient denies complaining dizziness or lightheadedness.
Eyes: blurriness in the right eye.
Ears: the patient reports tinnitus- right ear, but denies complaining of ear pain or ear discharge
Nose: the patient denies any nasal bleeding, discharge or obstruction
Mouth: the patient reports painful chewing, she denies gingival bleeding, having mouth sores, or having dental difficulties
Throat: no sore throat
Cardiovascular: the patient denies complaining of Chest pain, palpitations, or swelling in the legs.
Respiratory: the patient denies any wheezing, shortness of breath or coughing.
Gastrointestinal: the patient denies any nausea, vomiting, GERD, epigastric pain, diarrhea, constipation, having black stools, or blood in stool.
Genitourinary: the patient denies any dysuria, polyuria, or visible hematuria
Musculoskeletal: bilateral knee pain.
Integumentary (Skin): the patient denies having any skin rash or skin discolorations.
Neurological: the patient denies complaining of tingling or numbness in any extremity; there is no history of seizures, stroke, syncope, or memory changes.
Psychiatric: the patient denies complaining of depression, or anxiety, denies complaining of hallucinations.
Endocrine: the pat ...
12SOAP Note Patient with UTIUnited StateEttaBenton28
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
1
Health History
2
Health History
Health History
Name
Global Health College
Health Assessment
10/16/2015
Date __10/5/2015___
Examiner M. A.
1. Biographical Data
Initials __AM__ Phone __3017934596____
Address ___7001 96 Avenue, Lanham MD 20706
Birth date 07/28/1980 Birthplace Limbe, Cameroon___
Age __35__ Gender __Female__ Marital Status _Married__ Occupation _Nurse__
Race/ethnic origin __Black/Cameroon__ Employer __Karen For Kids Inc.__
2. Source and Reliability: The source of information is reliable because it is provided by the patient herself.
3. Reason for Seeking Care: Patient is seeking help because she has been having persistent diarrhea and abdominal cramps for two days.
4. Present Health or Health of Present Illness: Diarrhea and abdominal cramps.
Patient AM, came to the hospital at 4pm on 10/5/2015, complaining of persistent diarrhea and generalized abdominal cramps. She states that her illness started after she came back from a family swimming picnic on 10/2/2015 at 7pm. She states that her illness started with generalized abdominal cramping that was followed with her passing watery non-tarry stool with no foul smell. She says she has been having 5 episodes of diarrhea each day for two days. Patient also states that her illness is triggered when she eats any food or when she wants to do her daily exercise. Patient states she feels a little weak. Patient added that she has also taken Over The Counter (OTC) Imodium 4mg twice a day for two days but doesn’t feel any better. That is why she came to the hospital today for help.
5. Past Health
Ms AM says she has been healthy over the past years, except for today when she complains of diarrhea and abdominal cramps. She denies having any past history of childhood illnesses: measles, chicken pox, mumps, meningitis, impetigo. Patient confirms haven had pink eye at age 10years old, which was treated with some home remedies (soaked clean compress and OTC eye drop called artificial tears). Patient says she had a minor nose injury at age 12 years that was treated by her pediatrician with pain medication. Patient denies having history of any chronic illness: diabetes, hypertension, asthma, cancer, Congestive Heart Failure (CHF), Coronary Artery Disease (CAD), or stroke.
Patient denies haven been hospitalized before except during delivery. She also denies having any surgical procedures. Patient states that she has been pregnant three times, and she has three babies, two boys and one girl. She went ahead to say she had no premature procedures, delivery, abortion, or miscarriage. She added that all of her babies were carried full term and delivered after 9 months. of pregnancy. She labored for 4 hours for her first baby who was a boy, and 3 hours each for both second and third babies, a boy and a girl consecutively. She said her first baby weighed 7lbs and the other two weighed 8lbs each. All her three babies were delivered .
1[Shortened Title up to 50 Characters]2Week 9 Assignment.docxhallettfaustina
1
[Shortened Title up to 50 Characters] 2Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days du ...
1[Shortened Title up to 50 Characters]16Week 9 Assignment.docxhallettfaustina
1
[Shortened Title up to 50 Characters] 16Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days d ...
SubjectiveChief complaint headaches and blurriness of visi.docxpicklesvalery
Subjective:
Chief complaint: headaches and blurriness of vision on the right side
History of present illness: the patient is 67 years old Caucasian female, she complains of having had headaches for 2 weeks now. The pain is located in the right temporal area. She describes the pain as 8-10/10, sharp, constant, interferes with her sleep, she states that nothing aggravates it, not even the bright lights or high sounds, but she gets a little relief by taking Ibuprofen 800 mg. She stated that she has been having some blurriness in the right eye, while her left eye is fine. She also complains of pain in her jaw and tongue while chewing food. Her appetite has been low, and lost about 5 pounds in the last 2 weeks. She noticed low grade fever as well. She also reported ringing sounds in the right ear. She denies any nausea or vomiting. She denied having similar headaches in the past. The patient denies complaining of nasal or postnasal drainage.
PMH: past medical history is significant for Hypertension, type II diabetes mellitus, asthma, and degenerative arthritis of the knees.
PSH: hysterectomy
Medications: Lisinopril 10 mg PO QD
Metformin 500 mg PO BID.
Proair HFA 2 puffs PRN.
Ibuprofen 800 mg TID
Multivitamins
By comparing the medications that the patient is taking with Beers criteria, they all looked appropriate to be used in elderly patients.
Family Hx:
Father: HTN, diabetes, and stroke.
Mother: HTN, Diabetes, and breast cancer at the age of 72.
Social Hx: the patient never smoked tobacco products.
ETOH: social drinker
Illicit substances: denies ever using illicit drugs.
Allergies: penicillin.
Review of systems:
Constitutional: the patient complains of fever, fatigue, anorexia, and weight loss.
Head: the patient denies complaining dizziness or lightheadedness.
Eyes: blurriness in the right eye.
Ears: the patient reports tinnitus- right ear, but denies complaining of ear pain or ear discharge
Nose: the patient denies any nasal bleeding, discharge or obstruction
Mouth: the patient reports painful chewing, she denies gingival bleeding, having mouth sores, or having dental difficulties
Throat: no sore throat
Cardiovascular: the patient denies complaining of Chest pain, palpitations, or swelling in the legs.
Respiratory: the patient denies any wheezing, shortness of breath or coughing.
Gastrointestinal: the patient denies any nausea, vomiting, GERD, epigastric pain, diarrhea, constipation, having black stools, or blood in stool.
Genitourinary: the patient denies any dysuria, polyuria, or visible hematuria
Musculoskeletal: bilateral knee pain.
Integumentary (Skin): the patient denies having any skin rash or skin discolorations.
Neurological: the patient denies complaining of tingling or numbness in any extremity; there is no history of seizures, stroke, syncope, or memory changes.
Psychiatric: the patient denies complaining of depression, or anxiety, denies complaining of hallucinations.
Endocrine: the pat ...
12SOAP Note Patient with UTIUnited StateEttaBenton28
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
1
Health History
2
Health History
Health History
Name
Global Health College
Health Assessment
10/16/2015
Date __10/5/2015___
Examiner M. A.
1. Biographical Data
Initials __AM__ Phone __3017934596____
Address ___7001 96 Avenue, Lanham MD 20706
Birth date 07/28/1980 Birthplace Limbe, Cameroon___
Age __35__ Gender __Female__ Marital Status _Married__ Occupation _Nurse__
Race/ethnic origin __Black/Cameroon__ Employer __Karen For Kids Inc.__
2. Source and Reliability: The source of information is reliable because it is provided by the patient herself.
3. Reason for Seeking Care: Patient is seeking help because she has been having persistent diarrhea and abdominal cramps for two days.
4. Present Health or Health of Present Illness: Diarrhea and abdominal cramps.
Patient AM, came to the hospital at 4pm on 10/5/2015, complaining of persistent diarrhea and generalized abdominal cramps. She states that her illness started after she came back from a family swimming picnic on 10/2/2015 at 7pm. She states that her illness started with generalized abdominal cramping that was followed with her passing watery non-tarry stool with no foul smell. She says she has been having 5 episodes of diarrhea each day for two days. Patient also states that her illness is triggered when she eats any food or when she wants to do her daily exercise. Patient states she feels a little weak. Patient added that she has also taken Over The Counter (OTC) Imodium 4mg twice a day for two days but doesn’t feel any better. That is why she came to the hospital today for help.
5. Past Health
Ms AM says she has been healthy over the past years, except for today when she complains of diarrhea and abdominal cramps. She denies having any past history of childhood illnesses: measles, chicken pox, mumps, meningitis, impetigo. Patient confirms haven had pink eye at age 10years old, which was treated with some home remedies (soaked clean compress and OTC eye drop called artificial tears). Patient says she had a minor nose injury at age 12 years that was treated by her pediatrician with pain medication. Patient denies having history of any chronic illness: diabetes, hypertension, asthma, cancer, Congestive Heart Failure (CHF), Coronary Artery Disease (CAD), or stroke.
Patient denies haven been hospitalized before except during delivery. She also denies having any surgical procedures. Patient states that she has been pregnant three times, and she has three babies, two boys and one girl. She went ahead to say she had no premature procedures, delivery, abortion, or miscarriage. She added that all of her babies were carried full term and delivered after 9 months. of pregnancy. She labored for 4 hours for her first baby who was a boy, and 3 hours each for both second and third babies, a boy and a girl consecutively. She said her first baby weighed 7lbs and the other two weighed 8lbs each. All her three babies were delivered .
NURSING ASSESSMENT: -
• Patient feels discomfort & verbally explains her pain level.
• Pain level is also assessed by pain scale & verbal expressions.
• Slightly increase in temperature (1000 F)
• Patient feels itching on wound site & feels discomfort.
• Patient feels weakness & decrease in appetite.
• Patient & family members are confuse when I am asking questions.
NURSING DIAGNOSIS: -
Acute pain related to surgical incision as manifested by verbally explaining or discomfortness.
Risk for infection related to hospitalisation as manifested by slightly increase in temperature.
Impaired skin integrity related to improper dressing & vaginal discharge as evidenced by poor hygienic condition.
Imbalanced nutritional status related to anorexia as manifested by fewer intakes.
Deficit knowledge related to postpartum care & newborn care as manifested by poor hygiene condition.
SOAP NOTE
Name: J.D.
Date: 03/26/2020
Time: 2:00 pm
Age: 25 y/o
Sex: F
SUBJECTIVE
CC:
” I have a lot of pain on my left side, in my lower belly”
HPI: J.D. is a 25-year-old white female that came to the office today complaining of pain in her lower abdomen. The patient has always had painful cramps with her periods but this time it is much worse being described as a 6 out of 10 and lasting up to 5 hours. The pain started 2 days ago. The pain is described as more painful cramps. It is debilitating and prevents the patient from performing most daily activities. It is localized in the lower abdominal area, and sometimes radiates down her legs, and to her lower back. The patient uses hot compresses to relieve the pain as Tylenol does not work. The patient also states that she has been feeling nauseous ever since the pain started. She also urinates more frequently and pain on urination. Denies fever, vomiting, or chills.
Medications:
2 Tylenol as needed for her pain
PMH (include-immunization status including Gardisil, GTPLA).
Current or past illnesses: No current or past illnesses
Immunizations: All vaccines updated including flu vaccine and Gardasil.
Allergies: NKDA
Medication Intolerances: None.
Chronic Illnesses/Major traumas: None.
Hospitalizations/Surgeries (include delivery of pregnancies here)
No hospitalizations.
G0P0
Family History
Mother: 49 years old, no significant health problems
Maternal Side: No significant health problems
Father: 50 years old, hypertensive
Paternal Side: no significant health problems
Social History
Patient works full-time as a research assistant at a local university. A full-time student seeking a master’s degree in biochemistry at a local university. Married. Sexually active only with husband. Always uses male condoms as contraceptive device. Does not use recreational drugs, tobacco, or electronic cigarettes. Devout follower of Christianity. Denomination: catholic.
ROS
General Patient denies fever or chills, no weight changes.
Cardiovascular Denies chest pain, or discomfort. Denies palpitations, dyspnea, or orthopnea.
Skin: Denies presences of moles, rash, or itching.
Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic pains.
Eyes Denies problems or changes in her vision; denies double or blurred vision.
Gastrointestinal Positive for nausea.Denies hemorrhoids, constipation, or diarrhea. No variation in bowel habits. Denies vomiting.
Ears Denies difficulty or changes in his hearing. Denies tinnitus, or discharges.
Genitourinary/Gynecological Menarche 11 years old. Regular menstrual periods starting around the 3rd week of every month. LMP: 03.
1) Naïve T cells have the potential to differentiate into several MartineMccracken314
1) Naïve T cells have the potential to differentiate into several types of effector cells. In the space below, describe the roles and activities of each of these cells:
TH1 cells
TH2 cells
TH17 cells
TFH cells
2) Use the following diagram to compare and contrast systemic immunity and mucosal immunity.
Systemic
Both Systemic and Mucosal
Mucosal
ordinary surface epithelia
Why is there a need for these differences in the first place?
CDC Sexually Transmitted Diseases Case Study.
Read the patient case study below
General:
The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.
Chief Complaint:
Kim reports "I've been having pain in my stomach for several weeks." She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Source & Reliability of History:
O – "I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.
L – Both sides of her lower stomach
D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.
C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding
A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.
R – She stated that the pain remains steady and does not go away or radiate to other areas.
T- she reported feeling uncomfortable doing her regular shores due to the pain.
Past Medical history:
Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.
Family History:
She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.
Social History:
Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any ...
1) Naïve T cells have the potential to differentiate into several AbbyWhyte974
1) Naïve T cells have the potential to differentiate into several types of effector cells. In the space below, describe the roles and activities of each of these cells:
TH1 cells
TH2 cells
TH17 cells
TFH cells
2) Use the following diagram to compare and contrast systemic immunity and mucosal immunity.
Systemic
Both Systemic and Mucosal
Mucosal
ordinary surface epithelia
Why is there a need for these differences in the first place?
CDC Sexually Transmitted Diseases Case Study.
Read the patient case study below
General:
The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.
Chief Complaint:
Kim reports "I've been having pain in my stomach for several weeks." She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Source & Reliability of History:
O – "I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.
L – Both sides of her lower stomach
D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.
C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding
A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.
R – She stated that the pain remains steady and does not go away or radiate to other areas.
T- she reported feeling uncomfortable doing her regular shores due to the pain.
Past Medical history:
Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.
Family History:
She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.
Social History:
Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any ...
1
Week 9 Patient Comprehensive Exam
Walden University
NURS 6512 Advanced Health Assessment
Dr. Vijayarani Suresh
August 2, 2021
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2
Week 9 Patient Comprehensive Exam
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: T.J. Age:28 Gender: female
SUBJECTIVE DATA:
Chief Complaint (CC): “I’m here because I need a physical for my new job.”
History of Present Illness (HPI): T.J. is a 28-year-old African American female who is
here today for a general physical for a new job as an accounting clerk soon. She is
oriented to person, place, and time. She is calm, pleasant, and attentive. T.J. has dressed
appropriately for the season and is a good historian.
Medications: Metformin 850mg BID, last dose this morning
Flovent Inhaler two puffs twice daily, last used this morning
Albuterol Inhaler for rescue hasn’t been used recently. She states approximately three
months ago and has only used it twice last year.
Drospirenone/Ethinyl estradiol birth control, one pill daily. She started taking these four
months ago and was prescribed by her GYN MD. Last dose this morning.
Ibuprofen and Tylenol as needed
Allergies: Cats: makes asthma worse. PCN: “Not sure; I have been told this since I was a
child.” Denies any food allergies. She denies latex allergy. She states she does have some
environmental allergies.
Past Medical History (PMH): The patient has asthma, PCOS, and Type II Diabetes. She
states she checks her glucose every morning, and they have been stable. She has had
GERD in the past; however, she isn’t currently taking medication. She has only been
hospitalized for asthma as a child that she remembers and never for surgery. The patient
denies any severe injuries that would impair her. T.J. was seen for heart palpitations that
since then have subsided. She has been monitoring her blood pressure as it has fluctuated
at times but has now been normal. Last menstrual cycle was approximately two weeks
ago. The patient has never been pregnant and is up to date on her immunizations except
for the influenza vaccine. She recently had a routine pap smear; however, she needs to be
educated on how to do self-breast exams, as she states she has only had a doctor perform
this and doesn’t know what to look for. She denies any depressive or anxiety symptoms.
She has never had thoughts of harming herself or others, and She denies having a
transfusion. The patient states she was seen here a few months ago for a foot injury that
since then has subsided. She has back issues at times but is currently feeling well. The
This study source was downloaded by 100000830998373 from CourseHero.com on 04-29-2022 17:04:44 GMT -05:00
https://www.coursehero.com/file/1 ...
Soap Note 2 Chronic Conditions
Soap Note Chronic Conditions (15 Points)
Pick any Chronic Disease from Weeks 6-10
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Follow the MRU Soap Note Rubric as a guide
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement
SOAP NOTE SAMPLE FORMAT FOR MRC
Name:
LP
Date:
Time:
1315
Age:
30
Sex:
F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known med ...
Comprehensive SOAP TemplateThis template is for a full history.docxdonnajames55
Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Patient Initials: _______
Age: _______
Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes ofeach principal symptom in paragraph form not a list:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Includelast Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Mu.
Exercise ContentChief Complaint I fell down in my .docxrhetttrevannion
Exercise Content
Chief Complaint: “I fell down in my house a week ago and my knee is still hurting”.
History of Present Illness: Mr. Brown is 45-year-old male teacher who presents to the clinic with symptoms of right knee pain related to a fall sustained at home one week ago while he was coming down the stairs. Patient states that he tripped and during the fall, the right knee twisted and was caught between two bars of the stair wells. Immediately after the fall, the pain was sharp and stabbing, and he was unable to walk straight and apply weight on the knee. He applied ice and took 800mg of Motrin and went to bed. Patient states he did not want to go to the emergency department because of the long wait. After 24 hours he applied warm compresses intermittently and took extra strength Tylenol as needed. Mitigating factors include ES Tylenol, heat application, and resting the knee. However, sometimes the pain is so severe that even Tylenol does not help. Aggravating factors are standing too long, bending the knee, and climbing stairs. He describes the pain as sharp, and annoying at the same time. At present time he feels like "something is not right inside the knee”. Level of pain is 8/10. He denies previous musculoskeletal injuries.
Patient also reports shortness of breath but denies chest pain.
PMH: Asthma, bipolar disorder. Left knee anterior crucial ligament (ACL) 10 years ago from basketball injury.
Past surgical history: Right hip replacement 15 years ago from kick boxing.
Medications/OTC: Theophylline, Prednisone, Singular, Geodon, Prozac, Benadryl.
Allergies: NKA.
Past family history: One brother with asthma, and another brother with bipolar. Maternal aunt with DM type II.
Health Maintenance: Immunization up to date.
Social history: Patient does not smoke, drink or use recreational drugs. He maintains a regular diet and exercises 3 times a week. He has been married for 10 years and lives with his wife and one adult son, and one teenage daughter. He is a mathematics teacher in the same high school where he attends clinic. He sleeps well.
With the information provided above, please continue the patient’s soap note to include:
Subjective: A thorough review of systems
Objective: A thorough physical examination
Primary diagnosis
3 differential diagnosis with one citation for each ddx (APA formatted).
Laboratory tests
Diagnostic testing
Management plan
Medications
Non-pharmacological approach
Follow up
Patient education and Health promotion
References: A minimum of 3 different references are required for this assignment. All references must be properly APA formatted.
This assignment will be graded according to the rubric. Please have the Rubric handy when you are writing the soap note.
.
Running Head Clinical Diagnostic Zandria HamiltonMigr.docxtodd271
Running Head: Clinical Diagnostic
Zandria Hamilton
Migraine
Tyohon ID:1840-20181018-007
12/2/2018
CC:
" I've been having headache for a while"
HPI:
Patient is a 29-year-old Caucasian female who reports that she has had a headache for a year. She reports a headache is a constant dull ache located at the back of her neck. She reports the pain is a 6/10 at all times. She states that she has been taking ibuprofen 600 mg three times daily, but the medication provides no relief. She reports that the headache is worst during the day when she is out running every day errands.
PMH:
Patient reports no past medical history. Patient reports an MVA that occurred in 2016. Patient reports he sustained no injuries related to MVA. Patient denies having a past surgical history.
Allergies:
Reports no known medication, food or latex allergy.
Medication:
Patient reports the only medication she is currently on Ibuprofen 600 mg po TID as needed for headache.
Social History:
Patient denies recreational drug use. She denies tobacco use. She reports drinking two 8 oz glasses of wine 3 nights weekly. Patient reports she is married with 2 young girls aged 4 and 6. She reports she lives with her husband and 2 daughters. Reports she does not engage in risky sex. Patient reports she is a stay at home mother and is currently unemployed but reports she has a bachelor's degree in Spanish. She states she active member of the Catholic church and attend church every Sunday.
Family history:
Patient reports mother is still alive and has a history of hypertension which was diagnosed when she was 45. She states her father has a history of depression, which he was diagnosed with at age 39. Maternal grandmother died at the age of 83, from complications of CHF but medical history is unknown. Maternal grandfather died of complications of Parkinson's at the age of 75, but medical history is unknown. Paternal grandmother is still alive and medical history is unknown. Paternal grandfather is still a live and patient reports she doesn't know his medical history. Patient reports having 2 siblings who don't have any medical conditions.
Health maintenance and promotion:
Patient reports she was given a flu shot in December of 2017. She reports that she runs a mile 5 times a week in the morning. She reportedly drinks 84 oz. of water daily. She states that she eats a well-balanced diet. She reportedly eats 5 small meals a day. Based on Recommendations by the USPSTF the patient should be screened for high blood pressure in adults over the age of 18. The recommendation is to obtain measurement outside of the clinical setting for diagnostic confirmation before treating.
ROS:
General: Patient denies, fever, chills, or malaise.
Skin: Patient denies any open wounds, bruises, sores, or any areas of breakdown on skin.
HEENT: Patient denies abnormal growths on head. Patient denies having a hard time hearing. He denies ear pain. Patient denies tinnitus. She denies having a sore.
Gillian Barrie syndrome An autoimmune disease,
this presentation is a case discussion for actual case includes: demographic data, current history, past history, chief complaint, prognosis, medications, medical treatment, nursing management, disease pathophysiology.
Explain your current understanding of effective assessment practic.docxkendalfarrier
Explain your current understanding of effective assessment practices including the difference between summative and formative assessment and including the concepts of reliability, validity, and fairness.
Write about your belief in the worth of large-scale standardized tests and distinguish between norm-referenced and criterion-referenced varieties. How would you compare them with performance assessments (PBA or PBL) and formal observations?
Explain your understanding of appropriate and inappropriate test preparation and on your understanding of the practice of "teaching to the test," as well as ways to make it engaging and reduce test anxiety.
In a few sentences, give your understanding of the Response to Intervention progress-monitoring process and how it informs student tier placement.
Describe your beliefs in fair grading practices, including giving extra credit, allowing do-overs, assigning zeros for cheating or work not handed in, and the concept of giving exemplars, drafts, feedback, and student-friendly rubrics.
.
Explain why this would be a more appropriate classification than oth.docxkendalfarrier
Explain why this would be a more appropriate classification than other alternatives that you do not select.
2. Identify two major threats to the prosperity and stability of the developed countries. What, if anything, can those states do to reduce these threats?
3. What are the obstacles to development in many countries of the Global South? What seem to be the most appropriate strategies to overcome those obstacles? Why are such strategies not already successful?
4. Discuss key reasons why the military has often ruled in Global South countries and the conditions under which it come to power.
.
More Related Content
Similar to Nursing Process – SAMPLE Nursing DiagnosisNANDA (North American .docx
NURSING ASSESSMENT: -
• Patient feels discomfort & verbally explains her pain level.
• Pain level is also assessed by pain scale & verbal expressions.
• Slightly increase in temperature (1000 F)
• Patient feels itching on wound site & feels discomfort.
• Patient feels weakness & decrease in appetite.
• Patient & family members are confuse when I am asking questions.
NURSING DIAGNOSIS: -
Acute pain related to surgical incision as manifested by verbally explaining or discomfortness.
Risk for infection related to hospitalisation as manifested by slightly increase in temperature.
Impaired skin integrity related to improper dressing & vaginal discharge as evidenced by poor hygienic condition.
Imbalanced nutritional status related to anorexia as manifested by fewer intakes.
Deficit knowledge related to postpartum care & newborn care as manifested by poor hygiene condition.
SOAP NOTE
Name: J.D.
Date: 03/26/2020
Time: 2:00 pm
Age: 25 y/o
Sex: F
SUBJECTIVE
CC:
” I have a lot of pain on my left side, in my lower belly”
HPI: J.D. is a 25-year-old white female that came to the office today complaining of pain in her lower abdomen. The patient has always had painful cramps with her periods but this time it is much worse being described as a 6 out of 10 and lasting up to 5 hours. The pain started 2 days ago. The pain is described as more painful cramps. It is debilitating and prevents the patient from performing most daily activities. It is localized in the lower abdominal area, and sometimes radiates down her legs, and to her lower back. The patient uses hot compresses to relieve the pain as Tylenol does not work. The patient also states that she has been feeling nauseous ever since the pain started. She also urinates more frequently and pain on urination. Denies fever, vomiting, or chills.
Medications:
2 Tylenol as needed for her pain
PMH (include-immunization status including Gardisil, GTPLA).
Current or past illnesses: No current or past illnesses
Immunizations: All vaccines updated including flu vaccine and Gardasil.
Allergies: NKDA
Medication Intolerances: None.
Chronic Illnesses/Major traumas: None.
Hospitalizations/Surgeries (include delivery of pregnancies here)
No hospitalizations.
G0P0
Family History
Mother: 49 years old, no significant health problems
Maternal Side: No significant health problems
Father: 50 years old, hypertensive
Paternal Side: no significant health problems
Social History
Patient works full-time as a research assistant at a local university. A full-time student seeking a master’s degree in biochemistry at a local university. Married. Sexually active only with husband. Always uses male condoms as contraceptive device. Does not use recreational drugs, tobacco, or electronic cigarettes. Devout follower of Christianity. Denomination: catholic.
ROS
General Patient denies fever or chills, no weight changes.
Cardiovascular Denies chest pain, or discomfort. Denies palpitations, dyspnea, or orthopnea.
Skin: Denies presences of moles, rash, or itching.
Respiratory: Denies dyspnea, cough, hemoptysis, or pleuritic pains.
Eyes Denies problems or changes in her vision; denies double or blurred vision.
Gastrointestinal Positive for nausea.Denies hemorrhoids, constipation, or diarrhea. No variation in bowel habits. Denies vomiting.
Ears Denies difficulty or changes in his hearing. Denies tinnitus, or discharges.
Genitourinary/Gynecological Menarche 11 years old. Regular menstrual periods starting around the 3rd week of every month. LMP: 03.
1) Naïve T cells have the potential to differentiate into several MartineMccracken314
1) Naïve T cells have the potential to differentiate into several types of effector cells. In the space below, describe the roles and activities of each of these cells:
TH1 cells
TH2 cells
TH17 cells
TFH cells
2) Use the following diagram to compare and contrast systemic immunity and mucosal immunity.
Systemic
Both Systemic and Mucosal
Mucosal
ordinary surface epithelia
Why is there a need for these differences in the first place?
CDC Sexually Transmitted Diseases Case Study.
Read the patient case study below
General:
The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.
Chief Complaint:
Kim reports "I've been having pain in my stomach for several weeks." She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Source & Reliability of History:
O – "I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.
L – Both sides of her lower stomach
D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.
C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding
A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.
R – She stated that the pain remains steady and does not go away or radiate to other areas.
T- she reported feeling uncomfortable doing her regular shores due to the pain.
Past Medical history:
Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.
Family History:
She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.
Social History:
Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any ...
1) Naïve T cells have the potential to differentiate into several AbbyWhyte974
1) Naïve T cells have the potential to differentiate into several types of effector cells. In the space below, describe the roles and activities of each of these cells:
TH1 cells
TH2 cells
TH17 cells
TFH cells
2) Use the following diagram to compare and contrast systemic immunity and mucosal immunity.
Systemic
Both Systemic and Mucosal
Mucosal
ordinary surface epithelia
Why is there a need for these differences in the first place?
CDC Sexually Transmitted Diseases Case Study.
Read the patient case study below
General:
The patient is a young seventeen-year-old female who came to the clinic with complaint of abdominal pain.
Chief Complaint:
Kim reports "I've been having pain in my stomach for several weeks." She describes the pain as being sharp and being constant. She stated the pain often occurs on both sides of her lower abdominal. She has been experiencing the pain for the past two weeks. The pain has gotten worse since then.
Reliability and Source of History:
The patient is alert and oriented and able to answer most of the questions.
Source & Reliability of History:
O – "I have been having pain in my stomach for several weeks now.” she stated that the pain has lasted for two weeks without any relief.
L – Both sides of her lower stomach
D – The patient reported that she has been having this bilateral lower stomach pain for the last two weeks, However, the symptoms got worse since the pain started ago.
C – She stated that since the onset of the pain, her pain has remained constant without any relieve and aggravating factor. The pain is firm regardless of the time or day or event. She further stated that her symptoms get worse. The patient states that she is unaware of what caused the pain or how the pain started; however, she stated that taking pills could relieve her stomach pain and stop her bleeding
A – She stated that the pain remains constant. She also stated that she is unaware of what caused the pain or how the pain started.
R – She stated that the pain remains steady and does not go away or radiate to other areas.
T- she reported feeling uncomfortable doing her regular shores due to the pain.
Past Medical history:
Patient is asthmatic; however, her asthma is under control. She knows known history of any other condition or never been hospitalized.
Family History:
She is the second in a family of four who are all alive and healthy. There is no history of any chronic condition in the family.
Social History:
Patient is a regularly active young woman; she is single and does moderately active exercise. However, she stated that her daily activity and chores has recently reduced due to her recent symptoms of pain. She also stated to have no appetite secondary to her recent pain. She also stated that her stress level may be related with her college. She has no history of alcohol, smoking, or had never smoked in her life. She has not used any ...
1
Week 9 Patient Comprehensive Exam
Walden University
NURS 6512 Advanced Health Assessment
Dr. Vijayarani Suresh
August 2, 2021
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2
Week 9 Patient Comprehensive Exam
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: T.J. Age:28 Gender: female
SUBJECTIVE DATA:
Chief Complaint (CC): “I’m here because I need a physical for my new job.”
History of Present Illness (HPI): T.J. is a 28-year-old African American female who is
here today for a general physical for a new job as an accounting clerk soon. She is
oriented to person, place, and time. She is calm, pleasant, and attentive. T.J. has dressed
appropriately for the season and is a good historian.
Medications: Metformin 850mg BID, last dose this morning
Flovent Inhaler two puffs twice daily, last used this morning
Albuterol Inhaler for rescue hasn’t been used recently. She states approximately three
months ago and has only used it twice last year.
Drospirenone/Ethinyl estradiol birth control, one pill daily. She started taking these four
months ago and was prescribed by her GYN MD. Last dose this morning.
Ibuprofen and Tylenol as needed
Allergies: Cats: makes asthma worse. PCN: “Not sure; I have been told this since I was a
child.” Denies any food allergies. She denies latex allergy. She states she does have some
environmental allergies.
Past Medical History (PMH): The patient has asthma, PCOS, and Type II Diabetes. She
states she checks her glucose every morning, and they have been stable. She has had
GERD in the past; however, she isn’t currently taking medication. She has only been
hospitalized for asthma as a child that she remembers and never for surgery. The patient
denies any severe injuries that would impair her. T.J. was seen for heart palpitations that
since then have subsided. She has been monitoring her blood pressure as it has fluctuated
at times but has now been normal. Last menstrual cycle was approximately two weeks
ago. The patient has never been pregnant and is up to date on her immunizations except
for the influenza vaccine. She recently had a routine pap smear; however, she needs to be
educated on how to do self-breast exams, as she states she has only had a doctor perform
this and doesn’t know what to look for. She denies any depressive or anxiety symptoms.
She has never had thoughts of harming herself or others, and She denies having a
transfusion. The patient states she was seen here a few months ago for a foot injury that
since then has subsided. She has back issues at times but is currently feeling well. The
This study source was downloaded by 100000830998373 from CourseHero.com on 04-29-2022 17:04:44 GMT -05:00
https://www.coursehero.com/file/1 ...
Soap Note 2 Chronic Conditions
Soap Note Chronic Conditions (15 Points)
Pick any Chronic Disease from Weeks 6-10
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Follow the MRU Soap Note Rubric as a guide
Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement
SOAP NOTE SAMPLE FORMAT FOR MRC
Name:
LP
Date:
Time:
1315
Age:
30
Sex:
F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known med ...
Comprehensive SOAP TemplateThis template is for a full history.docxdonnajames55
Comprehensive SOAP Template
This template is for a full history and physical. For this course include only areas that are related to the case.
Patient Initials: _______
Age: _______
Gender: _______
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
O = onset of symptom (acute/gradual)
L= location
D= duration (recent/chronic)
C= character
A= associated symptoms/aggravating factors
R= relieving factors
T= treatments previously tried – response? Why discontinued?
S= severity
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes ofeach principal symptom in paragraph form not a list:
1. Location
2. Quality
3. Quantity or severity
4. Timing, including onset, duration, and frequency
5. Setting in which it occurs
6. Factors that have aggravated or relieved the symptom
7. Associated manifestations
Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, sexual function, and risky sexual behaviors.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Includelast Tdap, Flu, pneumonia, etc.
Significant Family History: Include history of parents, grandparents, siblings, and children.
Lifestyle: Include cultural factors, economic factors, safety, and support systems and sexual preference.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Mu.
Exercise ContentChief Complaint I fell down in my .docxrhetttrevannion
Exercise Content
Chief Complaint: “I fell down in my house a week ago and my knee is still hurting”.
History of Present Illness: Mr. Brown is 45-year-old male teacher who presents to the clinic with symptoms of right knee pain related to a fall sustained at home one week ago while he was coming down the stairs. Patient states that he tripped and during the fall, the right knee twisted and was caught between two bars of the stair wells. Immediately after the fall, the pain was sharp and stabbing, and he was unable to walk straight and apply weight on the knee. He applied ice and took 800mg of Motrin and went to bed. Patient states he did not want to go to the emergency department because of the long wait. After 24 hours he applied warm compresses intermittently and took extra strength Tylenol as needed. Mitigating factors include ES Tylenol, heat application, and resting the knee. However, sometimes the pain is so severe that even Tylenol does not help. Aggravating factors are standing too long, bending the knee, and climbing stairs. He describes the pain as sharp, and annoying at the same time. At present time he feels like "something is not right inside the knee”. Level of pain is 8/10. He denies previous musculoskeletal injuries.
Patient also reports shortness of breath but denies chest pain.
PMH: Asthma, bipolar disorder. Left knee anterior crucial ligament (ACL) 10 years ago from basketball injury.
Past surgical history: Right hip replacement 15 years ago from kick boxing.
Medications/OTC: Theophylline, Prednisone, Singular, Geodon, Prozac, Benadryl.
Allergies: NKA.
Past family history: One brother with asthma, and another brother with bipolar. Maternal aunt with DM type II.
Health Maintenance: Immunization up to date.
Social history: Patient does not smoke, drink or use recreational drugs. He maintains a regular diet and exercises 3 times a week. He has been married for 10 years and lives with his wife and one adult son, and one teenage daughter. He is a mathematics teacher in the same high school where he attends clinic. He sleeps well.
With the information provided above, please continue the patient’s soap note to include:
Subjective: A thorough review of systems
Objective: A thorough physical examination
Primary diagnosis
3 differential diagnosis with one citation for each ddx (APA formatted).
Laboratory tests
Diagnostic testing
Management plan
Medications
Non-pharmacological approach
Follow up
Patient education and Health promotion
References: A minimum of 3 different references are required for this assignment. All references must be properly APA formatted.
This assignment will be graded according to the rubric. Please have the Rubric handy when you are writing the soap note.
.
Running Head Clinical Diagnostic Zandria HamiltonMigr.docxtodd271
Running Head: Clinical Diagnostic
Zandria Hamilton
Migraine
Tyohon ID:1840-20181018-007
12/2/2018
CC:
" I've been having headache for a while"
HPI:
Patient is a 29-year-old Caucasian female who reports that she has had a headache for a year. She reports a headache is a constant dull ache located at the back of her neck. She reports the pain is a 6/10 at all times. She states that she has been taking ibuprofen 600 mg three times daily, but the medication provides no relief. She reports that the headache is worst during the day when she is out running every day errands.
PMH:
Patient reports no past medical history. Patient reports an MVA that occurred in 2016. Patient reports he sustained no injuries related to MVA. Patient denies having a past surgical history.
Allergies:
Reports no known medication, food or latex allergy.
Medication:
Patient reports the only medication she is currently on Ibuprofen 600 mg po TID as needed for headache.
Social History:
Patient denies recreational drug use. She denies tobacco use. She reports drinking two 8 oz glasses of wine 3 nights weekly. Patient reports she is married with 2 young girls aged 4 and 6. She reports she lives with her husband and 2 daughters. Reports she does not engage in risky sex. Patient reports she is a stay at home mother and is currently unemployed but reports she has a bachelor's degree in Spanish. She states she active member of the Catholic church and attend church every Sunday.
Family history:
Patient reports mother is still alive and has a history of hypertension which was diagnosed when she was 45. She states her father has a history of depression, which he was diagnosed with at age 39. Maternal grandmother died at the age of 83, from complications of CHF but medical history is unknown. Maternal grandfather died of complications of Parkinson's at the age of 75, but medical history is unknown. Paternal grandmother is still alive and medical history is unknown. Paternal grandfather is still a live and patient reports she doesn't know his medical history. Patient reports having 2 siblings who don't have any medical conditions.
Health maintenance and promotion:
Patient reports she was given a flu shot in December of 2017. She reports that she runs a mile 5 times a week in the morning. She reportedly drinks 84 oz. of water daily. She states that she eats a well-balanced diet. She reportedly eats 5 small meals a day. Based on Recommendations by the USPSTF the patient should be screened for high blood pressure in adults over the age of 18. The recommendation is to obtain measurement outside of the clinical setting for diagnostic confirmation before treating.
ROS:
General: Patient denies, fever, chills, or malaise.
Skin: Patient denies any open wounds, bruises, sores, or any areas of breakdown on skin.
HEENT: Patient denies abnormal growths on head. Patient denies having a hard time hearing. He denies ear pain. Patient denies tinnitus. She denies having a sore.
Gillian Barrie syndrome An autoimmune disease,
this presentation is a case discussion for actual case includes: demographic data, current history, past history, chief complaint, prognosis, medications, medical treatment, nursing management, disease pathophysiology.
Similar to Nursing Process – SAMPLE Nursing DiagnosisNANDA (North American .docx (20)
Explain your current understanding of effective assessment practic.docxkendalfarrier
Explain your current understanding of effective assessment practices including the difference between summative and formative assessment and including the concepts of reliability, validity, and fairness.
Write about your belief in the worth of large-scale standardized tests and distinguish between norm-referenced and criterion-referenced varieties. How would you compare them with performance assessments (PBA or PBL) and formal observations?
Explain your understanding of appropriate and inappropriate test preparation and on your understanding of the practice of "teaching to the test," as well as ways to make it engaging and reduce test anxiety.
In a few sentences, give your understanding of the Response to Intervention progress-monitoring process and how it informs student tier placement.
Describe your beliefs in fair grading practices, including giving extra credit, allowing do-overs, assigning zeros for cheating or work not handed in, and the concept of giving exemplars, drafts, feedback, and student-friendly rubrics.
.
Explain why this would be a more appropriate classification than oth.docxkendalfarrier
Explain why this would be a more appropriate classification than other alternatives that you do not select.
2. Identify two major threats to the prosperity and stability of the developed countries. What, if anything, can those states do to reduce these threats?
3. What are the obstacles to development in many countries of the Global South? What seem to be the most appropriate strategies to overcome those obstacles? Why are such strategies not already successful?
4. Discuss key reasons why the military has often ruled in Global South countries and the conditions under which it come to power.
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Explain why whistle-blowing is important to encourage in a firm. P.docxkendalfarrier
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David, F. (2011). 1.
Strategic management: concepts & cases
(Custom Edition ed., pp. 313-314). New York: McGraw-Hill Irwin.
No Wiki, Dictionary.com or Plagiarism
.
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.
Explain why there are two types of legal systems in the United State.docxkendalfarrier
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Note : should contain 500 words , citations included and references should be in APA format and include 3 references
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Explain why some organizations are accepting and other organizations.docxkendalfarrier
Explain why some organizations are accepting and other organizations are rejecting the use of Bitcoins as a standard form of currency. Document needs to identify two major companies that have adopted Bitcoin technology as well as one that has refused accepting Bitcoin as a form of currency. Be sure to discuss each organization, how they adopted (or why they won't adopt) Bitcoin, and what recommendations you have for them to continue to support Bitcoin (or why they should support Bitcoin).
Document should be:
Be approximately four in length, not including the required cover page and reference page.
Follow APA7 guidelines. Document should include an introduction, a body with fully developed content, and a conclusion.
0 % plagariasm
.
Explain why relativism and egoism pose a challenge to the possib.docxkendalfarrier
Explain why relativism and egoism pose a challenge to the possibility of rational discussion in ethics. Using the readings in our text and my Weekly Comments, show how these doctrines might be challenged.
Feminist Care Ethics might be seen as a challenge to Kantian Ethics. Explain with reference to the readings in our text and my Weekly Comments.
Feminist Care Ethics might be seen as a form of Virtue Ethics with the major difference being a disagreement about the nature of human excellence and the virtues necessary for acting ethically. Explain with reference to the readings in our text and my Weekly Comments.
Explain the Trolley problem and the differences in the ways that utilitarianism, Kantian deontology, and Virtue Ethics would address the problem. Base your answer on the readings in our text and my Weekly Comments.
Both Utilitarianism and Kant's deontological ethics sometimes lead to morally horrendous actions related to the sanctity of human life. Kantian ethics is able to avoid the morally horrendous actions that can be justified using Utilitarianism, while Utilitarianism can avoid the morally horrendous actions that accord with Kantian ethics. Virtue ethics, though, would not have the same sorts of problems addressing issues discussed in the text, such as torturing terrorists if it were necessary to save lives, the Trolley Problem, killing an innocent person to save the lives of others, lying or making a false promise to save the lives of others. Explain with reference to the readings in our text and my Weekly Comments, using specific examples of the types of cases that would provide problems for each of the theories.
Week 2: Ethical Relativism
Ethical Relativism is the claim that moral views are relative to the culture in which one lives or to the individual (also called Subjectivism). Many people declare themselves to be ethical relativists, but very few actually believe it to be true in practice. Often people are simply trying to avoid getting into an argument when they say that their ethical positions are just opinions. If it was true that you should avoid arguments about ethical issues, you would have to believe that there are good moral or possibly prudential reasons for not getting into arguments with others, that it was good for everyone to avoid conflict about controversial issues, which means that it is simply correct to be tolerant, making you opposed to relativism. Since you would be claiming that tolerance is a virtue that everyone should accept. In other cases, you may be concerned with ethnocentrism, the practice of imposing your views on others. But then, you would have to believe that being ethnocentric is morally wrong and that there are good moral reasons for not being ethnocentric. All of the people in the class took tolerance to be a moral virtue, some claiming that it is a result of cultural relativism. But you can’t derive a universal value from cultural relativism. And Daesh (ISIL, ISIS) and the Taliban .
Explain which steps of intelligence collection and counterterrorism .docxkendalfarrier
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APA citation, 3 to 4 References within 5 years.
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Explain what the textbook author says about each theme present. Pr.docxkendalfarrier
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2. Clearly express your opinion or points-of-views about the themes, and what the textbook author says, etc.
3.
In your Precise (Summary) statement include:
a.
What you learned from the content of the project
b.
What information you agreed/disagreed with
c.
What specific leadership and followership ethical lessons you took away from each film
d.
Include whether you enjoyed the presentations or not, and why
e.
Include any other information you may want to share about the Comprehensive Final Project
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Essay 250 words APA
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Your response should be at least 200 words in length. All sources used, including the textbook, must be referenced; paraphrased and quoted material must have accompanying citations.
David, F. (2011). 1.
Strategic management: concepts & cases
(Custom Edition ed., pp. 330-337). New York: McGraw-Hill Irwin.
No Wiki, Dictionary.com or Plagiarism
.
Explain the various forms of social engineering tactics that hackers.docxkendalfarrier
Explain the various forms of social engineering tactics that hackers employ and provide an example of each.
Describe the five social norms of hacker subculture and provide an example of each.
Search Internet news sources and find a recent article on hacking. Describe the tone in regard to hacking and explain what the article conveys in regard to stigmas and labels surrounding the hacker.
.
Explain the two major types of bias. Identify a peer-reviewed epidem.docxkendalfarrier
Explain the two major types of bias. Identify a peer-reviewed epidemiology article that discusses potential issues with bias as a limitation and discuss what could have been done to minimize the bias (exclude articles that combine multiple studies such as meta-analysis and systemic review articles). What are the implications of making inferences based on data with bias? Include a link to the article in your reference.
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Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
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Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
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Model Attribute Check Company Auto PropertyCeline George
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Nursing Process – SAMPLE Nursing DiagnosisNANDA (North American .docx
1. Nursing Process – SAMPLE Nursing Diagnosis
NANDA (North American Nursing Diagnosis)
Chronic Painrelated to unknown etiology
as evidenced by self-reports of pain “I feel
pain when sitting or lying down mostly at night” using a
standardized pain scale, 4/10 on a 0 to 10 numeric rating scale.
The patient reports an altered sleep-wake cycle.
Patient Goal/Outcome
Interventions
Rationale for Interventions
Evaluation of Each Goal/Intervention
1)The Patient’s pain will reduce and her sleep will promote by
using nonpharmacological methods such as supplements or
enhance pharmacological interventions within the next three
months.
1a) RN will in addition to administering analgesics, support the
client's use of nonpharmacological methods to help
control pain, such as distraction, imagery, relaxation, and
application of heat and cold.
1b) RN will ask the client to describe prior experiences with
pain, effectiveness of pain management interventions,
responses to analgesic medications (including occurrence of
side effects), and concerns about pain and
its treatment (e.g., fear about addiction, worries, anxiety) and
informational needs.
2. 1a) Evidence
suggested efficacy and satisfaction when complementary
therapies are integrated into pain treatment plans of
older adults (Bruckenthal, 2016 as cited in Ackley et al., 2022,
p. 723).
1b) Sleep disturbance and decreased physical activity are
adverse
effects of people with chronic pain. In a study of clients with
chronic pain, those who participated in a 4 week
multiprofessional program that included psychoeducation and
training related to pain, sleep, exercise, and
activity training had improvement in sleep quality and pain
intensity (de la Vega, 2019, as cited in Ackley et al., 2022, p.
721).
1a) Goal partially met. Patient’s pain decreased to level 2/10,
with relaxation therapy such as meditation and usage of heat
pads.
3. 1b) Goal met. Patients starts to drink Valerian root tea and
states “It reduced the amount of time takes me to fall asleep and
helped me sleep better.”
Health history assignment part 1
Section 1: Biographic Data
N.V is a 46-year-old married Iranian woman, who currently is a
full-time financial manager at BMW company. She speaks
fluent English and does not require an interpreter.
Section 2: Source of History
The patient provides the information herself. The patient seems
reliable, as she is alert and oriented.
Section 3: Reason for Seeking Care
The patient states, “I am really exhausted and want to get rid of
my leg pain. I have severe pain in my thighs and legs and it
started six years ago.”
Section 4: History of Present Illness (HPI)
The patient’s thigh and leg pain began six years prior to the
interview. Her pain started following the birth of her second
child. The patient has frequent episodes, the last being three
4. days ago. It has never been resolved. It is specially located in
the thighs and legs, sometimes includes back pain, and does not
radiate to other regions. It mainly felt in the evening and at
bedtime when the patient sitting or lying down. The duration is
vary depending on the amount of activity that the patient has on
that day, the longest being 48 hours and the shortest being 1
hour. The patient feels dull pain in the muscles that rates as 6
on the pain scale from 0 to 10. Lying down aggravates the
symptoms. The patient has been using warm compresses and
pressure massage to relieve pain. No treatments have been used.
The patient denies having medical, surgical, or psychiatric
conditions that are significant to the current condition.
Review of Related Body System- Musculoskeletal:
Patient reports having muscle pain in her legs. She sometimes
experiences back pain as well. She feels the pain in the evening
and at bedtime when the patient sitting or lying down. The
patient denies cramps, weakness, coordination problems with
activities, mobility aids, or assistive devices used. The patient
denies arthritis, gout, or any pain, stiffness, swelling,
deformity, or noise in her joints.
Health Promotion: Patient states that she walks about 500-1000
steps per day at work.
Section 5: Past Health
Childhood Illnesses
Patient has had mumps and denies a history of chicken pox,
measles, rubella, pertussis, and strep throat. The mumps was
lasts for two weeks and were treated by bed rest, plenty of
fluids, and painkillers. There were no complications.
Accidents or Injuries
patient denies any accidents or injuries.
Serious or Chronic Illnesses
patient denies any serious illnesses. Denies history of asthma,
5. depression, diabetes, hypertension, heart
disease, HIV infection, hepatitis, sickle-cell anemia, cancer, and
seizure disorder.
Hospitalizations
patient reports being hospitalized for nose surgery at Mahan
hospital in 1996 for one night and two vaginal deliveries, at
Cedars-Sinai hospital in 2001 and at Mission hills hospital in
2016. She was treated with ibuprofen for pain, and had no other
complications.
Operations
Patient has nose cosmetic surgery in 1996 at Mahan hospital in
Tehran, Iran with Dr.Akbari. she stays one night at the hospital.
She was prescribed pain medication during recovery.
Obstetric History
Gravida: 2
Term: 2
Preterm: 0
Ab: 0
Living: 2
The first pregnancy reached full term at nine months and was
two weeks late before delivery. It was a vaginal delivery. The
baby was a male, 7.2 Ib., and healthy. The second pregnancy
reached full term at nine months and was one week late before
delivery. It was a vaginal delivery. The baby was a male 7.5 ib.,
and healthy. Patient denies postpartum complications with both
pregnancies.
Immunizations
Patient states that she has no record of previous immunizations,
due to the records being lost.
Psychiatric History
Patient denies psychiatric history.
6. Last Physical Examination
Last examination was April 2022. Vitamin D deficiency and a
borderline thyroid. No other abnormal finding.
Allergies
Patient has allergies to eggplant and pepper, which cause rashes
and itching. The patient notes do not use any medication for her
allergy. NKDA.
Current Medications
Name
Date
Dose
Reasons for Medication
Multivitamin
QD
500 mg, tablet, PO
Improve immune
Vitamin D-3
QD
25 mcg, 1 drop, PO
Improve D deficiency
Hairtamin
QD
250 mg, tablet, PO
Improve hair growth
Ibuprofen
PRN
600 mg, tablet, PO
Pain relief
Patient denies taking aspirin, antacids, or cold remedies. Denies
any home or herbal remedies.
7. Section 6: Family History
Mother, living, age 81, history of hypertension. Father, living,
age 87, history of prediabetes. Sister, living, age 61, history of
uterus cancer, and lung cancer. Brother, living, age 55, history
of hypertension. Brother, living age 58, healthy. Brother, living,
age 50, healthy. Maternal grandmother, deceased, age 65, bone
cancer. Maternal grandfather, deceased, age 67, prostate cancer.
Paternal grandmother, deceased, age 85, healthy. Paternal
grandfather, deceased, age 72, history of diabetes type 2.
Husband, living, age 52, history of hypertension. Son, living,
age 20, healthy. Son, living, age 6, healthy.
Patient denies family history of coronary heart disease, stroke,
obesity, blood
disorders, alcohol or drug addiction, mental illness, suicide,
kidney disease, and
tuberculosis.
genogram
Section 7: Review of Systems (ROS)
General: The patient states that she considers herself to be
healthy. She recently starts gaining weight. Patient deny any
other illness, fatigue, weakness, malaise, fever, chill, sweat or
night sweat.
SKIN, HAIR & NAILS: Patient denies history of skin disease,
rashes or lesions, pigment or color change, change in moles,
excessive dryness or moisture, pruritus, and excessive bruising.
Recently, her hair started to fallen in the last 1 year ago.
8. Health Promotion: Patient states she uses sunscreen (UVA/UVB
SPF 35) only on her face. Patient does not use sunblock on
entire body daily. Patient Denies using indoor tanning beds.
Patient denies performing monthly skin self-examination.
Patient states she is in sun 2 to 3 hours a day.
Head: No abnormal findings. Patient denies severe headaches,
head injuries, dizziness, and vertigo.
Health promotion: She always uses seat belt and drive through
speed limits while driving.
Eyes: Patient states she does not have clear sight for far objects,
but she never met any physician and does not try any treatment.
Patient denies blurring, blind spots, eye pain, diplopia, redness
or swelling, watering or discharge, history of glaucoma or
cataracts.
Health promotion: Patient states fatigue weaken her eye sight
too.
EARS: Patient denies any earaches, infections, discharge and its
characteristics, tinnitus, or vertigo. No hearing loss or usage of
hearing aid. Patient states she cannot recall her last evaluation
with a physician.
Health promotion: The patient cleans her ears regularly. Patient
notes she is exposed to light environmental noise.
NOSE & SINUSES: Patient states she had cosmetic surgery on
her nose 27 years ago. She denies any unusually frequent or
severe colds, sinus pain, nasal obstruction, nosebleeds,
allergies, hay fever, or change in sense of smell
9. MOUTH & THROAT: Patient denies any frequent sore throat,
bleeding gums, toothache, lesion in mouth or tongue, dysphagia,
bad breath, history of tonsillectomy, or altered taste. The
patient states her voice sounds hoarse sometimes.
Health Promotion: Patient brushes her teeth twice a day and
flosses every night before bed. Dentist cleaning appointment
once a year. The last dental visit was on 09/22, Dr. Mousavi,
had no abnormal results including cavities.
Neck: No abnormal findings. Patient denies pain, limitations of
motion, lumps, swelling, lumps, enlarged or tender nodules,
goiters, and recent neck injuries.
Breast/Axilla: No abnormal findings. Patient denies breast pain,
or unusual nipple discharge, or history of breast surgery or
implants. She founded a lump in her left breast and diagnosed
with fibroadenoma but states no treatment has been used for it.
Health Promotion: Patient does breast self-examination every
month and last mammogram was in 2021, result shows no
abnormal finding.
RESPIRATORY: Patient denies any lung disease (asthma,
emphysema, bronchitis, pneumonia, tuberculosis), shortness of
breath. She states she is exposed to a clean environment to
breathe. The patient states she cannot recall her last TB test and
chest X-ray.
Cardiovascular: Patient denies chest pain, palpitation, cyanosis,
orthopnea, paroxysmal nocturnal dyspnea, history of heart
murmur, coronary artery disease, heart failure, and previous MI.
Patient states she cannot recall her last EGG or other cardiac
10. tests.
Peripheral Vascular: patient denies coldness, numbness,
tingling, swelling of legs, discoloration, intermittent
claudication, thrombophlebitis, and ulcers. The patient has
varicose veins in her right calf, and the patient states that she
doesn’t know when to get them.
Health Promotion: The patient reports some days has prolonged
sitting or standing. The patient notes to always crosses her legs
at the knees and not wear a support hose.
GASTROINTESTINAL: Patient denies any nausea, vomiting,
hematemesis, dysphagia heartburn, reflux, indigestion,
abdominal pain, abdominal disease, excessive belching or
flatulence. She has bowel movements two or three times a day.
She also denies any recent change in stool characteristics,
constipation or diarrhea, black or tarry stools, rectal bleeding,
rectal conditions such as hemorrhoids or fistula.
Urinary: Patient states she has no nocturia and urinates 3 times
a day. Patient notes urine is a lighter yellow, no presence of
hematuria. Patient denies dysuria, polyuria, oliguria, hesitancy,
straining, narrowed stream, kidney disease, kidney stones,
urinary tract infections and incontinence.
Genital Female: Patient states having begun her menses at age
12. She states has regular menstruation, with 5 days, every 28
days. Her last menstrual period starts on 28th September till 2th
October. The patient notes having weak pain during
menstruation, but denies having bleeding between periods or
after intercourse, vaginal discharge, or itching.
11. Sexual Health: Patient is sexually active. Patient denies being
exposed to gonorrhea, herpes, Chlamydia, HPV, HIV/AIDS, or
syphilis. The patient denied HPV vaccine, and notes never
having had an STD test.
Musculoskeletal: See History of Present Illness.
Neurologic: Patient denies history of seizures, strokes, syncope,
paralysis, local weakness, numbness, tingling, or tremors. Pt
denies changes in memory or concentration, changes in mood,
tension, nervousness, depression, hallucinations, or suicidal
thoughts.
Health Promotion: Patient does not recall having the
meningococcal vaccine due to immunization records being lost.
Hematologic: Patient denies having anemia, easy bruising, or
bleeding and having a history of blood transfusions.
Endocrine: Patient denies diabetes, heat or cold intolerance,
excessive sweating, excessive thirst, eating, or urination. she
states she has borderline thyroid but does not use medication for
it.
Health Promotion: Patient cannot recall the date of the last
glucose test but denies ever having an abnormal result.
Section 8: Functional Assessment
Self-Esteem/Self Concept
The Patient has a diploma from her backcountry in 1994. No
history of military service. The patient is currently employed
12. full-time, 45 hours a week, as a financial manager at BMW
Rusnak. The patient is highly satisfied. The patient denies
having any current health problems now that may be related to
this health exposure. Patient denies working with health hazards
such as asbestos, inhalants, chemicals, or repetitive motions.
Patient confirms having health insurance.
Activity / Exercise
The patient reports being comfortable with all daily activities,
such as eating, bathing, hygiene, dressing, walking, standing,
and climbing stairs. No use of assistive devices was reported.
Patient states achieving one hour of exercise every day through
working, and cleaning.
Sleep / Rest
Patient reports sleeping 5-6 hours a night. She goes to bed at
2300 and wakes up at 0500. The patient has difficulty with
insomnia a couple of times a week. Patient not seeking
treatment for insomnia. Patient does not use medication to fall
asleep.
Nutrition
The patient is 5”8 and 155 Ib., with a BMI of 23.6 kg/m2. The
patient’s intake within the last 24 hours consists of: Breakfast:
1 boiled egg – 2 slices whole grain bread- ½ cup cucumber- 1
medium size tomato- 1 cup tea - 1 tablespoon honey. At 1100: 1
cup of blueberry- 20 oz of water. Lunch: 0.5 Ib. salmon fish- 6
tablespoons white rice- 1 cup cooked broccoli and carrot- 1 cup
salad (chopped cucumber-onion-tomato with lemon juice and
olive oil)- 1 cup low-fat yogurt drink- 20 oz of water. At 1600:
2 scoops ice-creams - 18 oz of water. Dinner: 10-ounce pasta
with fried ground beef and tomato sauce and 2 tablespoons
parmesan cheese - 2 tablespoon ketchup sauce- ½ cup fat-free
yogurt- 20 oz of water. The patient states that “this can be” a
typical daily diet for most days. The Patient prepares her own
food. The patient has sufficient finances for food. She describes
13. eating with her husband and coworkers for most mealtimes. She
has food tolerance to eggplant and pepper due to an allergy. The
patient reports not drinking coffee and has a protein base diet.
Interpersonal Relationships/Resources
Patient has been married for 26 years, and a mother of 2 for 20
years. The patient notes she and her husband share expenses in
the family. The patient states that she is close to her sister and
husband, but she goes to a friend or God to seek emotional
support.
Spiritual Assessment
Patient denies any specific religion and states that she just
believes in God. She explains God has a huge impact on her life
and she prays to Him sometimes. She doesn’t belong to any
community. And denies speaking more in detail about it.
Coping and Stress Management
Patient notes the stress in her life is worrying about her
children’s future and her parents due to their age. The patient
denies taking medication but distracts herself when gets
stressed by music or doing shopping. The patient notes a
personal strength is being helpful to others.
Environment / Living Conditions
Patient lives at the house with her family. Patient reports that
their home has no stairs, and is located in a safe neighborhood,
with sufficient utilities and heat. The patient owns her own
vehicle and can drive herself.
intimate Partner Violence / Elder Abuse
Patient denies any abuse, harm, or emotional harm from either
her husband or family. The patient states that she feels safe
around the members of her family.
Personal Habits
14. Tobacco: patient denies any tobacco use.
Alcohol: patient denies alcohol consumption.
Drugs (medication & recreational/illicit): patient denies drug
use.
Cultural, Ethnic and Racial Background:
Patient identifies as Iranian, and culturally considers herself to
be Caucasian. The patient notes being born in Tehran, Iran, and
moving to The United States, California, when she was 22 years
old and where she remains living to this day. The patient denies
practicing any cultural or ethnic traditions that may relate to her
health. Patient denies having any ethnic or cultural impactions
on her choice of diet.
Section 9: Perception of Health
Patient’s goal is to minimize or eliminate the pain in her legs.
the patient notes “she gets suffered for too long, she seeks
treatment many times but they weren’t able to find an effective
treatment.” “She reports that some nights she cries from pain
and wanted their son to sit on her lap to reduce the pain”
Section 10: Problem Lists
Actual Problems: leg pain- back pain- insomnia- hoarse voice.
Potential/Risk Problems: borderline thyroid, lump in breast,
varicose vein, visual impairment, hair loss, weight gain, allergy.
AUDIT – C
Questions
Scoring System
Your score
15. 0
1
2
3
4
How often do you have a drink containing alcohol?
Never
Monthly or less
2-4 times
Per month
2-3
times
per
week
4+
times
per
week
0
How many units of alcohol do you drink on a typical day when
you are drinking?
1-2
3-4
5-6
7-9
10+
0
How often have you had 6 or more units if female, or 8 or more
if male, on a single occasion in the last year?
Never
Monthly or less
2-4
times
per
month
16. 2-3
times
per
week
4+
times
per
week
0
TOTAL SCORE: ___0___
Scoring: Total of 5+ indicates increasing or higher risk
drinking.
An overall total score of 5 or above is AUDIT-C positive.
Remaining AUDIT – C questions
Questions
Scoring System
Your score
0
1
2
3
4
How often during the last year have you found that you were not
able to stop drinking once you had started?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
How often during the last year have you failed to do what was
17. normally expected from you because of your drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
How often during the last year have you needed an alcoholic
drink in the morning to get yourself going after a heavy
drinking session?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
How often during the last year have you had a feeling of guilt or
remorse after drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
How often during the last year have you been unable to
remember what happened the night before because you had been
drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
Have you or somebody else been injured because of your
drinking?
No
18. Yes, but not in the last year
Daily or almost daily
0
Has a relative or friend, doctor or other health worker been
concerned about your drinking or suggested that you cut down?
No
Yes, but not in the last year
Daily or almost daily
0
Scoring: 0-7 Lower risk, 8-15 Increasing risk, 16-19 Higher
risk, 20+ Possible dependence
TOTAL score equals =
AUDIT C Score (above) + Score of remaining questions
TOTAL SCORE: ___0___
Drug Screening Questionnaire (DAST – 10)
Using drugs can affect your health and some medications you
may take. Please help us provide you with the best healthcare
by answering the questions below. When the words “drug
abuse” are used, they mean the use of prescribed or over-the-
counter medications/drugs in excess of the directions and any
non-medical use of drugs.
Which recreation drugs have you used in the past 12 months?
☐ Methamphetamines (speed, crystal)
☐ Cannabis (marijuana, hash)
☐ Inhalants (paint thinner, aerosol, glue, etc.)
☐ Tranquilizers (valium)
☐ Cocaine (crack)
☐ Narcotics (heroin, hydrocodone, oxycontin, etc.)
☐ Other __________None___________
19. image1.png
image2.png
APA FORMAT – QUICK GUIDE (with locations in APA
Publication Manual, 7th ed.)
Sources for help with APA format:
• APU Writing Center
https://www.apu.edu/writingcenter/
• Purdue Online Writing Lab (OWL)
https://owl.purdue.edu/owl/purdue_owl.html
TITLE PAGE (Chp 2)
No running head, author note or abstract unless
specifically asked for by instructor (2.2, 2.8)
Title page elements (2.3)
title, author(s), affiliation, course number & name,
instructor name, and due date
Title (2.4) title case, bold, centered, upper half of pg.
Put in one blank double-spaced line between
title and byline (2.5)
BODY OF PAPER (Chp 2)
Put title of paper on first line of the first page of text
(2.11) title case, bold, centered
Appendices (2.14) - begin each on a separate page,
20. give each a label and title (on separate lines,
sentence case, bold, centered)
Order of pages (2.17)
title page, text, references, appendices
Page numbers (2.18) - insert page numbers in the
top right corner, title page is page number 1
Keep consistent double-spacing (2.21)
- do not add blank lines before or after headings
- do not add extra space between paragraphs
- MS Word Line Spacing - 3-minute video describes
how to set your paper for correct line spacing
https://www.youtube.com/watch?v=FIe_9FhV2jk
One-inch margins - keep consistent (2.22)
Right margin - do not justify (2.23)
Indent first line of every paragraph (2.24)
No header or title for introduction (2.27)
Headings format - see chart on this page (2.27)
WRITING STYLE & CLARITY (Chp 4)
Tighten language to eliminate wordiness (4.6)
Avoid contractions and colloquialisms (4.8)
Revise your final draft (4.30) into a polished
paper by reviewing central points, assignment
parameters and assignment rubric, if provided
Check and proofread for spelling and grammar!
bold
https://www.apu.edu/writingcenter/
21. https://owl.purdue.edu/owl/purdue_owl.html
https://www.youtube.com/watch?v=FIe_9FhV2jk
MECHANICS (Chp 6)
Insert one space following punctuation at the
end of sentences (6.1)
Comma (6.3) - see APA manual for a full list of uses
Use to set off the year in parenthetical in-text
citations, e.g. (Horowitz, 2019, p. 214)
Sentence case (6.17) - in a title or heading lowercase
most words and capitalize only these: first word of
title or heading, first word of subtitle, first word
after a colon, em dash, end punctuation in a
heading, nouns followed by numbers or letters,
and proper nouns
Title case (6.17) - in a title or heading capitalize the
first word, first word of subtitle, first word after
a colon, em dash, end punctuation in a heading,
major words, and word of four letters or more
(With, Between, From)
Italics (6.22) - see APA manual for full list
Use italics for: title of books, reports, webpages,
periodicals, and periodical volume numbers in
reference lists
Abbreviations, use and definition (6.24, 6.25)
- use it at least three times in the paper
- do not define abbreviations that are listed as
terms in the dictionary (e.g., AIDS, IQ)
- when the full version of a term is first used in a
sentence in the text, place the abbreviation in
parenthesis after it. e.g., attention-
deficit/hyperactivity disorder (ADHD)
22. Numbers (6.33) - spell out (use the word for)
numbers zero through nine and for any number
that begins a sentence
IN-TEXT CITATIONS (Chp 8)
Each work cited must be in the reference list
and vise-versa (8.4)
Secondary source citation format (8.6)
In-text citation format (8.10)
With parenthetical citation at the end of a
sentence, put period or other end punctuation
after the closing parenthesis.
Citing multiple works (8.12)
separate multiple citations with semicolons
Unknown or anonymous author (8.14)
Number of authors for in-text citations (8.17)
- 3 or more use et al. every time, including first time
- use an ampersand in parenthetical citations
- spell out “and” in narrative citations
Direct quote (8.25) - always provide page number
Single page “p. 2”. Multiple pages “pp. 2-6” (8.25)
REFERENCE LIST (Chp 9 & 10)
Start on a new page (2.12, 9.43)
Label with “References”
capitalized, bold, centered (2.12, 9.43)
Punctuation for entries (9.5) - see APA manual
periods, commas, and parentheses
Identify author correctly (9.7, 9.11)
- an institution, government agency or organization
23. is considered the author unless otherwise specified
- see examples 111 & 112 in chapter 10 (10.16)
Provide surnames and initials (9.8)
- no first names or credentials
- for up to 20 authors
Use a serial comma before ampersand that
comes before last author’s name (9.8)
One space between initials (9.8)
No author format (9.12)
Group authors (9.11) - including gov. agencies,
associations, hospitals, businesses
- spell out organization name in the reference list
unless it does not appear this way
- an abbreviation for the group author can be
used in the text
Retrieval dates are not needed for the
majority of references (9.16, 10.16)
If the title ends in a question mark or exclamation
point, that punctuation replaces the period (9.19)
Sentence case (9.19) - see APA manual
Periodical sources format (9.25)
- title as shown on the work (use title case, italics)
- volume (italics)
- issue (in parenthesis with no space after volume)
- page range or article number
- end with a period
- follow with DOI or URL as applicable
Italics (9.19, 9.25) - see APA manual
Publisher’s location (9.29) - do not include
24. Designations of business structure (9.29) - do not
include; no Inc., Ltd., LLC
Write author’s name as it appears in the published
work; retain preferred capitalization (9.9)
DOIs & URLs format (9.35)
- no “Retrieved from…”; links should be live
- no period after
Alphabetize (9.43)
Double-space the ENTIRE reference page (9.43)
- within and between entries
- double space after the label References
Hanging indent (9.43) - apply to each entry
Format for “edition” is ed. (9.19 & 9.50) e.g., 8th ed.
DMay Rev 10/2022
1
Health History Assignment – Part 2
Student Name
School of Nursing, Azusa Pacific
University
25. GNRS 578, Health
Assessment
Instructor’s Name
Date
2
Health History Assignment – Part 2
No sample. Please include an introduction that frames
the purpose and application/uses of
a health history. For guidance, refer to the beginning of Jarvis,
Chapter 4.
Problem Lists
26. This patient is an 80-year old Caucasian female. The
actual problems for this patient are
bilateral leg edema, difficulty walking, obesity, hypertension,
hyperglycemia, joint pain, back
pain, depression, and anxiety. The potential problems for this
patient include risk for clots due to
immobility, risk for diabetes mellitus, risk for dehydration, risk
for fall and risk for infection due
to incomplete immunizations.
Assessment and Analysis
Patient Perspective of Presenting Problem
The presenting problem of bilateral leg edema is not much of a
concern for the patient.
Since that patient has experienced this before and the edema has
resolved with diuretics, the
patient believes that the edema will resolve with the same
treatment. The edema does not
contribute to her anxiety nor impact her life. The patient only
describes the edema as
inconvenient when she needs to wear shoes to go to her doctor’s
appointments. The patient is
lying down most of the day, so she does not notice the leg
swelling or weight gain from the
27. swelling. She states that the cardiologist has told her she does
not have a heart issue and she
believes her edema is caused by her immobility. She reports that
she needs to move around more
to possibly prevent water accumulation in her legs and avoid
gaining more weight. The patient is
more concerned about her overall additional weight gain from
the swelling, aside from her
sedentary lifestyle and overeating. The patient does not have
any spiritual concerns that need to
be addressed.
3
Overview of Significant Concern Areas
The presenting symptom of edema of the bilateral lower
extremities is the major concern
area for the patient with associated mild weight gain. Since the
patient’s physician ruled out any
heart conditions, the patient believes her immobility is causing
the issue and that she needs to
move around more. In one study that was conducted on
individuals with gait disturbances and
28. without any venous abnormalities or systemic diseases,
successful management of leg edema
was achieved through compression and physical therapy
(Suehiro et al., 2014). With these
findings, it was assumed that leg edema was due to immobility
that caused venous stasis
(Suehiro et al., 2014). Since the patient has difficulty walking
herself, she should get help from
outside sources, such as physical therapists and compression
therapy as suggested by evidence-
based research. With the patient lying down most of the day
and usually only noticing her leg
edema when she must wear shoes, the patient must also pay
more attention to the swelling
variations of her lower extremities. While the presenting
problem of bilateral leg edema does not
cause the patient much suffering, it is important for the patient
to monitor daily weight changes
to notice worsening symptoms. Daily weight monitoring allows
for early detection of excess
fluid volume which can be balanced out with medication
increases to prevent the need for
hospitalization (Wagner & Harden-Pierce, 2014, as cited in
Ackley et al., 2020).
29. The patient also has difficulty walking, which causes
her to walk extremely slowly. The
patient should start to walk more during the day, even if it
means walking for a few minutes and
gradually progressing her way up the block. Even slow walking
with turns can preserve muscle
mass and strength, facilitating further independence (Araki et
al., 2017, as cited in Ackley et al.,
2020). Walking can also prevent venous stasis, which is a risk
factor for clots (Huether &
McCance, 2020). As discussed above, the patient’s issue of
having difficulty walking due to her
4
rheumatoid arthritis and back pain should be intervened by
health professionals if the patient
cannot motivate herself. Another study done to increase
physical activity in patients suffering
from rheumatoid arthritis, revealed that posttreatment and 6-
month follow up appointments
greatly increased the number of patients meeting the physical
activity recommendations (Knittle
30. et al., 2015, as cited in Ackley et al., 2020). Through
motivation and professional management,
the patient can be guided in a specific direction and be
encouraged to self-monitor her times
spent on physical activity and more.
Having a body mass index (BMI) of 32.9 kg/m2 put the
patient in the obese category.
The patient notes that she does not exercise and barely moves
around due to the pain in her
joints. She is aware that her sedentary lifestyle and overeating
is contributing to her weight gain.
A moderate weight loss approach is suggested for the geriatric
population with a BMI over 30
(Ackley et al., 2020). It is recommended to limit simple
carbohydrate intake and instead focus on
balanced high-quality nutrients, which includes high-quality
meats of around 1.2 g per kg of
body weight (Blaze, 2016, as cited in Ackley et al., 2020).
Since the patient’s daughter makes
most of the food and rice is usually eaten with Persian dishes
she makes, the daughter needs to
limit including it with the meals. Based on the patient’s weight,
she should be limiting high-
quality meats to around 98 grams as well.
31. Since the patient has rheumatoid arthritis, gait difficulty due to
pain and a history of falls,
the patient is at risk for falls (Potter et al., 2021). The patient’s
most recent fall was caused by
slipping on the rug by her bed. The patient should remove any
throw rugs, declutter her home
and install adequate lighting in the house to help prevent falls
(Potter et al., 2021).
Chronic depression and anxiety have been an issue with
the patient for many years and
both concerns are part of the patient’s family history. The
patient reports feeling depressed or
5
anxious due to her inability to move about as she wishes. It has
previously been found that 30 to
50% of chronic pain patients have depression as a comorbidity
(Breivik et al., 2014, as cited in
Ackley et al., 2020). The patient states that she uses the
television to distract herself most of the
time. If the patient begins to feel anxious or down, there are
other techniques she can use to try to
32. feel better such as visualizing herself without anxiety and such,
successful experiences of
situations or resolution of conflicts (Ackley et al., 2020). This
strategy of guided imagery has
been used as a psycho-supportive intervention due to promoting
comfort (Satija & Bhatnagar,
2017, as cited in Ackley et al., 2020).
The patient has a family history of colon cancer on her father’s
side. New technology has
brought about the fecal immunochemical test (FIT) that detects
blood from an ulcer or polyp in
the colon from an individual’s stool sample (Jarvis, 2020). With
the patient having a family
history of colon cancer and having her last colonoscopy 3 years
ago, the FIT test is a simple,
noninvasive tool that the patient can do annually to detect
possible abnormalities of the colon
sooner. If the test is ever positive, the patient will then have to
do a colonoscopy to confirm
colon cancer or determine the next steps (Jarvis, 2020).
Evaluation of Nutritional Data
The patient reports eating cheese as part of her
breakfast meal every day. Since the
33. patient has a history of hypertension, she should become aware
of foods that have high amounts
of salt in them, including dairy. It is recommended that people
who have hypertension follow the
dietary approaches to stop hypertension (DASH) diet, which
suggests reducing sodium intake to
less than 2300mg per day (Grodner et al., 2020). The patient
also consumes rice regularly, which
is made with added salt by her daughter. One major way of
reducing sodium intake is to avoid
adding salt when making rice (Grodner et al., 2020). Reducing
salt intake can also help treat the
6
patient’s presenting problem of bilateral leg edema (Huether &
McCance, 2020). The daughter
can take pre-portioned meals instead of a large container of rice
to help the patient lose calories
since she is considered obese and is not exercising. During
breakfast, the patient usually has
bread as well. Since the patient is eating a similar breakfast
daily, she should substitute her bread
for a whole-grain bread. This will help fulfill the suggesting
34. seven to eight servings of grain
products, that increases intake of minerals and fibers (Grodner
et al., 2020). Chocolate and ice
cream is eaten just about every day too, which can contribute to
high amounts of sugar. Not only
does the patient have to reduce this intake to adhere to the
recommended 5 servings a week of
the DASH diet (Grodner et al., 2020), the patient needs to
decrease her sugar intake because of
her diagnosis of hyperglycemia and to reduce the risk of its
progression to diabetes mellitus. In
addition to contributing to extra glucose and calories, the daily
intake of ice cream is a source of
saturated fat and does not fulfill the recommended 3 servings of
low fat or non-fat dairy products
(Grodner et al., 2020). The patient should instead turn to low fat
or non-fat dairy products like
frozen yogurt to comply with the recommendations of reducing
saturated fat and total fat or at
least buy a healthier version (Grodner et al., 2020).
Although the patient can apply many of these
modifications, one of the patient’s strengths
is satisfying the recommended 4 to 5 servings of fruits per day
(Grodner et al., 2020). Another
35. one of her strengths is eating fresh poultry, fish, and lean meats
rather than fattier foods or cured
meat (Grodner et al., 2020). The patient does not really
consume fatty foods. While the older
population is more at risk for Vitamin D deficiency (Grodner et
al., 2020), the patient does take
supplements to prevent this, especially since she is not under
the sun much. While it is currently
unlikely, it is possible for the patient to become deficient in
Vitamin B12 later due to the general
decrease of intrinsic factor production in the older population,
which helps with absorption
7
(Grodner et al., 2020). The patient notes drinking about 4 cups
of water a day, rather than the
recommended 8 glasses (Grodner et al., 2020). Due to the
patient’s presenting problem of
bilateral leg edema, the amount of water the patient drinks
should be discussed with her
physician to prevent further complications.
36. 8
Nursing Diagnosis
NANDA:
Excess fluid volume related to excessive sodium intake as
evidenced by peripheral edema
and weight gain.
Patient
Goal/Outcome
Interventions Rationale for
Interventions
37. Evaluation of Each
Goal/Intervention
Patient will explain
at least two actions
that are needed to
treat or prevent
excess fluid volume
including dietary
restrictions and
medications as well
as maintain the
appropriate body
weight of 178
pounds within the
next 6 weeks.
1a) RN will assist
patient in switching
38. to a restricted-
sodium diet and
will teach patient
how to
appropriately take
diuretics prescribed
by the provider.
1b) RN will help
patient monitor
daily weight for
sudden increases
using the same
scale and type of
clothing at the same
39. time each day,
preferably before
breakfast.
1a) Restricting the
sodium in the diet
will favor the renal
excretion of excess
fluid (Rudge &
Kim, 2014 as cited
in Ackley et al.,
2020, p. 414).
…diuretics should
be initiated in
the…client who
presents with
significant fluid
overload…to
40. reduce morbidity
(Yancy et al., 2013
as cited in Ackley
et al., 2020, p. 194).
1b) Body weight is
commonly used to
monitor for fluid
overload (Wagner
& Harden-Pierce,
2014 as cited in
Ackley et al., 2020,
p. 413).
1a) Goal met. Patient was
able to explain two
actions that are needed to
treat or prevent excess
fluid volume: avoiding
41. bringing the saltshaker to
the table during meals
and checking her blood
pressure before taking
one dose of diuretics in
the morning then the
second dose no later than
4 p.m. as prescribed.
1b) Goal met. Patient
reports a noticeable
decrease in peripheral
edema and is now
weighing at 178 pounds
each morning before
breakfast using the same
scale and type of clothing
42. after adhering to a
restricted-sodium diet
and use of diuretics.
9
References
Ackley. B. J., Ladwig, G.B., Makic, M. B. F., Martinez-Kratz,
M., & Zanotti, M. (2020).
Nursing diagnosis handbook: An evidence-based guide to
planning care (12th ed.).
Elsevier.
Grodner, M., Escott-Stump, S., & Dorner, S. (2020). Nutritional
foundations and clinical
applications: A nursing approach (7th ed.). Elsevier.
Huether, S., & McCance, K. (2020). Understanding
pathophysiology (7th ed.). Elsevier.
Jarvis, C. (2020). Physical examination and health assessment
(8th ed.). Elsevier.
Potter, P., Perry, A., Stockert, P., Hall, A. (2021).
Fundamentals of nursing (10th ed.). Elsevier.
43. Suehiro, K., Morikage, N., Murakami, M., Yamashita, O., Ueda,
K., Samura, M., & Hamano, K.
(2014). A study of leg edema in immobile patients.
Circulation Journal: Official Journal
of the Japanese Circulation Society, 78(7), 1733–1739.
https://doi.org/10.1253/circj.cj-13-
1599
GNRS 578
Health Assessment Lab
Week 10
Health History Assignment
Health History Assignment
Week 10 - Q&A for Part 2 & NANDA. Review APA format.
The APU Writing Center is a terrific resource for help
with writing and formatting.
https://www.apu.edu/writingcenter/
44. The Writing Center exists to support students, faculty,
and staff across APU’s campuses, including regional
locations. They provide free one-on-one, group,
and/or
remote tutoring services.
Week 11 - Part 2 due Mon, Nov 7.
Another sample NANDA
,
,
APA Format
Title Page
APA Manual 2.3(deductions if not met)Title of paper – title
case, bold, centered, in upper half of page.
An additional double-spaced blank line appears between the
title and the byline.
Includes: affiliation, course number & name, instructor name,
assignment due date.
Page number in top right corner. Introduction
2Includes an introduction that frames the purpose and
45. application/uses of a health history.
This is not an introduction to your patient.
Please refer to the beginning of chapter 4 in Jarvis for guidance.
Problem Lists
2Restates the problem lists from Part 1.
Please make changes to your lists based on feedback for
Part 1.
Two lists show problems as actual problems or potential/risk
problems (includes health promotions concerns).
Problems are listed in priority order.Patient
Perspective6Addresses:
what it’s like to have this problem according to the patient
the impact on his/her life
what they believe to be the cause of the problem
suffering experienced by the patient; includes description of
patient’s fears and concerns
any signs of spiritual distress
Health History Assignment RUBRIC for PART 2
Significant Concern Areas12Based on the information collected,
includes personal and family history information.
Citations are included to provide evidence/source to support
discussions. Evaluation of Nutritional Data
6Identifies areas of strength and deficiencies, including an
assessment of patient’s intake of salty and fatty foods.
Gives suggestions for improved nutritional well-being,
including a plan to incorporate the changes needed based on the
lifestyle of the person, income, job schedule, personal and
cultural preferences, exercise, and sleep patterns. Nursing
Diagnosis14Applies nursing process to one priority problem
identified.
Problem is within a nurse’s scope of practice.
Diagnosis is selected from NANDA (North American Nursing
46. Diagnosis Association) Nursing Diagnosis Handbook, Ackley.
Diagnosis is formulated correctly with “related to” and “as
evidenced by”. Goal is specific, measurable, appropriate,
reasonable, with a time frame (SMART).
Includes two patient-specific nursing interventions that will
accomplish the goal.
Rationale with a reference is given for each intervention.
Provide an in-text citation.
Evaluation (or how evaluation would be done) is included.
APA Format
(deductions if not met)
Presents as an academic paper in narrative form.
Follows 7th ed. APA format, including page numbers, content
format (margins, spacing, indentation, headings, section labels,
and other), in-text citations and reference page.
Provides a minimum of 3 references. One point deduction for
less than 3.
Check all punctuation in citations and reference
list.Grammar, Spelling and Punctuation
(deductions)Maximum 10% deduction for errors.Organization
and Flow
(deductions)Maximum 10% deduction for significant
problems.Submitted on Time
(deductions)Please submit assignment to Canvas. Lecture Site
10% deduction in total grade for each day late.TOTAL
42Please see graded assignment in Canvas to view earned
points along with instructor comments and annotations.
When viewing assignment grading, look at comments in the
47. rubric and feedback in the document.
APA Format (7th ed.)
Chapter 2 – Paper Elements and Format
Title Page (2.3) / Fig 2.2 for sample
- title of paper – title case, bold, centered, in upper half of
page
An additional double-spaced blank line appears
between the title and the byline.
- affiliation, course number & name, instructor name,
assignment due date
- page number in top right corner
Running head (2.8) only if instructor requests (not needed for
HH Paper)
Text/Body (2.11)
On the first line of the first page of the text, write the title
of the paper in title case, bold, and centered.
The text should be left aligned, double-space the entire
paper (2.21 Line Spacing) with the first line of each paragraph
indented.
Do not start a new page or add extra line breaks when a
new heading occurs; each section of the text should follow the
next without a break.
48. Heading Levels (2.27)
Formatting a Reference List
Each source you cite in the paper must appear in your reference
list; likewise, each entry in the reference list must be cited in
49. your text.
Your references should begin on a new page separate from the
text of the essay; label this page "References" in bold, centered
at the top of the page (do NOT underline or use quotation marks
for the title).
All text should be double-spaced, including between and within
references.
First line of each entry should be flush left with subsequent
lines indented.
Alphabetize!
Reference List (2.12)
Reference List - Basic Rules for Most Sources
All lines after the first line of each entry in your reference list
should be indented one-half inch from the left margin.
All authors' names should be inverted (i.e., last names should be
provided first).
Authors' first and middle names should be written as initials.
50. For example, the reference entry for a source written by
Jane Marie Smith would begin with "Smith, J. M.“
If a middle name isn't available, just initialize the author's
first name: "Smith, J.“
Give the last name and first/middle initials for all authors of a
particular work up to and including 20 authors. (This is a new
rule, as APA 6th ed. only required the first six authors).
Separate each author’s initials from the next author in the list
with a comma. Use an ampersand (&) before the last author’s
name. If there are 21 or more authors, use an ellipsis (but no
ampersand) after the 19th author, and then add the final author’s
name.
Reference List - Basic Rules for Most Sources (cont’)
Reference list entries should be alphabetized by the last name of
the first author of each work.
For multiple articles by the same author, or authors listed in the
same order, list the entries in chronological order, from earliest
to most recent.
When referring to the titles of books, chapters, articles, reports,
webpages, or other sources, use sentence case - capitalize only
the first letter of the first word of the title and subtitle, the first
word after a colon or a dash in the title, and proper nouns.
Italicize titles of longer works (e.g., books, edited collections,
names of newspapers, and so on).
Do not italicize, underline, or put quotes around the titles
of shorter works such as chapters in books or essays in
51. edited collections.
Begin each appendix on a new page AFTER References.
Give each appendix a label and title. For one appendix, label it
“Appendix”. If more then one, label each with a capital letter
(A, B, C, etc.) in the order in which it is mentioned in the text.
The appendix title should describe its contents.
The appendix title should describe its contents.
Each appendix should be mentioned at least once in the text.
Place the label and title in title case, bold and centered on
separate lines at the top of the page on which the appendix
begins.
Appendices
(2.14)
No appendices needed for the Health History Assignment.
52. This is for future reference.
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