Occupation of Client/Patient: Retired Health History/Review of Systems (Complete and systematic review of systems) Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications): Neurologically JP is intact. She speaks clearly, denies headaches, dizziness, and weakness. She admits that she often forgets where she has left her car keys or glasses, but feels it is due to her busy lifestyle. Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): JP has chronic neck pain related to a career of dancing. In 2010 after an x-ray and a MRI she was diagnosed with torticollis. . At times, she needed to take Flexeril 5mg orally as needed, and Lortab 5/500mg orally as needed, to alleviate spasms and pain. She sees now a chiropractor twice a month, and denies any problems for 2 years, since beginning her chiropractic regimen. Torticollis results in spasms of the sternocleidomastoid, trapezius, and other neck muscles, usually more prominent on one side than the other, caused by turning or tipping of the head (Kruer, 1994/2012).
Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications):JP has Myopia. She wears glasses to correct this. She reports that her mother had Glaucoma, but denies having it herself. Her last eye exam was April 2012. Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications): JP reports that her hearing is “better than good.” She feels this is due to her poor sight, and that her body has compensated for her loss. She has had no surgeries. She admits to having chronic sinus problems and sometime that causes her ears to hurt. Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): JP reports frequent rhinorrhea, and sinus pain. She self-treats this with over the counter Claritin-D 10/240mg. She reports that she does not like the nasal spray her doctor prescribed and prefers the decongestant in the Claritin-d. JP feels that she has seasonal allergies, more from fall to spring months. She has never had an allergy test. Jp’s last dental visit was June 2012, where she had her teeth cleaned and 2 cavities filled. She reports that she brushes her teeth only in the mornings.
The decongestant in Clartin-D is Pseudoephedrine sulfate, which is the synthetic salt of one of the naturally occurring dextrorotatory diastereomers of ephedrine. It is classified as an indirect sympathomimetic amine, and is in the amphetamine class. The American Dental Association recommends that adults brush their teeth two times a day. Research has shown that infections in the mouth may be associated with heart disease, stroke, diabetes, pneumonia and other health problems that are common in older adults (American Dental Association, 2012). Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications): JP has thin papery skin. She bruises easily, she feels this is due to the 81mg Aspirin she takes daily. She has Plaque Psoriasis on her elbows, knees and hands, and has had this since her mid 20’s. JP reports that her sisters also have Psoriasis, as does her daughter and her grandson. At times, this affects JP because she cannot pick up her grandchildren due to psoriasis on her hands.
She uses Diprolene Ointment, 0.05%, on her knees and elbows, and Pandel Cream, 0.1% on her hands. Psoriasis is a chronic, autoimmune disease that appears on the skin. It occurs when the immune system sends out faulty signals that speed up the growth cycle of skin cells. Research has found that missing protein in deoxyribonucleic acid (DNA) may have errors, thus making Psoriasis inheritable (National Psoriasis Foundation, 2012). Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications):JP reports that she has had breast implants since she was in her late 20’s (1978). They are silicone and saline, double lumen implants. She performs self-breast exams in the shower monthly, and her physician exams her yearly for her physical. She refuses to have a mammogram, due to it being “painful sounding”. She denies pain, discharge, and history of breast disease. Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications):JP reports that she does not have leg cramps or pain, but that she does have “spider veins.
She checks her ankles frequently for swelling, but has not found any yet. Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications): JP tires easily. Though she does not have a family history of cardiac issues, she frequently worries that her “heart is slowing down.” She occasionally experience chest pains. She take 81 mg Aspirin daily. Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications): JP quit smoking in 1984. She denies lung disease and asthma. She exercises frequently by hiking, and reports that her lungs are “darn good”. Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity of daily living, medications): JP gets right hip pain after long hikes. She visits a chiropractor two times a month, and he adjusts her neck, hip and low back.
She reports that she was in a car accident 4 years ago and that is what caused her lower back problems. Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications): JP reports that she only eats two times a day, breakfast and dinner. She snacks on fruit in between meals. She reports that she is not constipated because she drinks benefiter daily. She reports that sometimes she gets diarrhea if she snacks too much. Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, suprapubic region or low back): JP reports that she used to get frequent urinary tract infections, but she has not had one for several years. She takes cranberry tablets if she begins to feel frequency and that “fixes it”. She wakes frequently through the night to urinate. Physical Examination (Comprehensive examination of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory assessments): JP can move her facial muscles at will. She is able to smile, frown, raise her eyebrow, close her eyelids, whistle, and puff her cheeks.
Her face is symmetrical, with no involuntary muscle movements. She is able to clench her jaw. She can identify salty, sweet and sour substances. All cranial nerves are intact. Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland): JP’s head is round and is normocephalic, with no tenderness upon palpation. She has oily thin black hair, without lice or dandruff. Eyes (test visual acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus): JP has symmetrical black eyebrows, with evenly place blue eyes that appear flat. Her sclerae are white, her pupils are PEARRLA. Both conjunctivae are pinkish, and no ulcers are noted. There is a positive corneal reflex noted. She is able read a Snellen eye chart top line without her glasses on, and then she can read the smallest line. No nystagmus noted. Ears (inspect external structure, otoscopic examination, inspect tympanic membrane, test hearing acuity): The ear lobes are symmetrical, bean shaped, and slightly uneven with the right ear slightly higher than the left.
The pinna recoils. JP’s auricles are have a firm cartilage on palpation, with no tenderness. No discharge noted, with some brownish red cerumen noted in both ears. The membrane is flat, and pearly gray in color. Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat): JP’s nose is midline without discharge. The nasal septum is midline. The nasal mucosa is reddish pink. Both nares are patent. The frontal and maxillary sinusitis is tender to palpation. No Temporomandibular crepitous noted. Gums are pinkish, without bleeding. Receding gums noted on lower front teeth. No dental carries and no halitosis. Tongue has no lesions or varicosities. JP is able to move her tongue freely. Her tonsils were removed at age 6. Her trachea is midline, with no nodules. Her thyroid is not palpable. She has range of motion in her neck, but audible “popping sounds” accompany movement. Skin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture, inspect and palpate nails, contour, color, teach self-examination techniques): JP has Plaque Psoriasis on her elbows, knees and hands.
Psoriasis appears as scaly, erythematous patches with silvery scales on top (Jarvis 249).Skin color is pink on aspects without the psoriasis. There is a scar on her left anterior lateral wrist from a glass bottle cut when she was 42. The is a tattoo of a small yellow butterfly on her right lateral ankle, and a red heart with a cupid bow on her left breast. Breasts and Axilla (deferred for purpose of class assignment) Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses; inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps): Radial pulses are palpable, strong, and equal. R 68, L68. Her legs show no venous engorgement. Small varicose veins noted on the left posterior aspect of the calf. Skin color is pink, slightly pale. Pedal pulse is also strong and equal, R 66, L 66. Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S1 and S2, any extra heart sounds, murmur): No jugular vein distention. No lift, heave, or pulsation over the aortic, pulmonic, or mitral valves. Heart sounds are strong and regular, with S1S2 audible at all anatomic sites. Heart rate is 66.
Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds): Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, range of motion; inspect shoulders for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect elbows for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect hips for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect knees for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and range of motion): Extremities are equal in size, with equal contraction, and no involuntary movements. JP is able to counter act gravity and resistance on ROM. All extremities can perform complete range of motion.
There is no edema and no crepitus. Extremity color is even. Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution; auscultate bowel sound;, percuss all four quadrants; percuss border of liver; light palpation in all four quadrants– muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness): Contour is flat with no visible peristalsis. Skin is pink with striae noted on lower abdominal quadrants. No aortic pulsation noted. No tenderness, with bowel sound noted in all 4 quadrants. The liver cannot be palpated. Tension is smooth and consistent with no muscle guarding. Genitourinary System (deferred for purpose of this class) FHP Assessment Cognitive-Perceptual Pattern: JP completed the VARK assessment and found that aural/write learning was prevalent for her.
Two of her children had Hyperactivity, and Attention Deficit Disorder, and she was diagnosed with this herself at age 12, but her mother refused to allow treatment. She does not appear to get distracted easily. BE AS SPECIFIC AS POSSIBLE IN EACH OF THE FOLLOWING CATEGORIES Nutritional-Metabolic Pattern: JP The recently changed to a diabetic, cardiac diet, due to her A1C being 6.5, and her cholesterol is 220. Her triglycerides are 195. She chose to eat diabetic and cardiac for improved health. She takes Fish oil with Vitamin D 1000mg, three times daily. According to the American Heart Association 2012, cholesterol is controllable, and a major factor in risk for coronary artery disease, stroke, and heart attack (AHA, 2012). Sexuality-Reproductive Pattern: JP is Gravida 3, Para 3, Abortus 0. She has three adult sons, and 6 grandchildren. She started menopause early at age 46, and denies complications. JP take Estroven over the counter, but reports that she doesn’t take it all the time. JP is not in a relationsip and is not sexually active at this time, thought she reports that she is hopeful. Pattern of Elimination: JP reports good elimination habits, and has daily bowel movements usually early in the morning. Her stools are soft, and formed.
She takes Benefiber daily. Pattern of Activity and Exercise: JP belongs to a hiking group in Las Vegas. As she is retired, she hikes 3-4 times a week. She goes to the gym 1 time a week to swim and enjoys the steam room. She feels this keeps her lungs healthy. Pattern of Sleep and Rest: JP uses Benadryl and hot teas to promote sleep. She often does not go to bed until midnight, and sleeps about 4 hours before waking up to go to the bathroom. She has tried to stop drinking fluids early in the evening but feels this does not help. Pattern of Self-Perception and Self-Concept: JP appears to be a well-adjusted, happy American female. She has been a widow for 3 years, and feels that she is now more outgoing than she was while married. She is the youngest of 7 siblings, of which only 5 are still alive. She speaks to her brothers and sisters weekly but enjoys living in a different city from them. Jp feels that her health is better than many people her own age.
Summarize Your Findings (Use format that provides logical progression of assessment.) Situation (reason for seeking care, patient statements): JP is a 62-year-old American female. She weighs 155lbs and is 5’3. She presents with Right hip pain, after hiking a 6-mile hike at Red Rock. She denies dyspnea or chest pain but report pain 8/10 in her right hip when walking. She reports the pain started approximately 5 mile into the hike, and that the pain occurs regularly upon hiking downhill. JP denies osteoporosis. Background (health and family history, recent observations):The patient has a history of right hip pain after hiking or walking, and visits a chiropractor regularly. She has not had an X-ray or MRI previously. She takes Naproxen 220mg for this condition. Assessment (assessment of health state or problems, nursing diagnosis):VSS= T 36.5, P66, BP 128/64. Patient grimaces upon walking. Gait steady, ambulation independent. No visually hip deformity noted. Pedal pulses +2, regular. Pupils are PERRLA, Lung sounds are clear bilaterally and heart rate is regular with S1S2 audible. Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education): X-ray, possible MRI, Chemistry panel, CBC, Phosphate, TSH, 24 hour urine test. Dual-energy x-ray absorptiometry (DXA) scan.
Follow-up care with Physical therapy. Patient teaching related to using antishock hiking poles for enhanced stability and support (REI Staff, 2012). Patienbt teaching related to stretching muscles prior to exercising. Stretching the muscles and tendons that surround the joint can help with some causes of hip pain (Cluett, 2012). The FRAX® algorithms give the 10-year probability of fracture. The FRAX® tool has been developed by WHO to evaluate fracture risk of patients. It is based on individual patient models that integrate the risks associated with clinical risk factors as well as bone mineral density .The output is a 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (Kanis, 2012). JP’s FRAX score is: Major Osteoporotic 0.6, hip fracture risk 0.0.
Nursing Diagnosis: Activity Intolerance, Relate To: overexertion, As Evidence By: reported pain upon ambulation after longer hikes.
Intervention 1: Teach JP to stop hiking or activity immediately and report to the physician if she experiences the following symptoms: new or worsened intensity or increased frequency of discomfort; tightness or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger.
Rationale: These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician (Ackley 119).
Patient Outcome: JP will recognize when to stop activity due to cardiac blood flow.
Intervention 2: Refer JP to physical therapy for resistance exercise training, including abdominal crunch, leg press, leg extension, leg curl, calf presses.
Rationale: Six months of resistance exercise for the elderly greatly increased their aerobic capacity, possibly from increased skeletal muscle strength (Ackley 121).
Patient Outcome: JP will show increased tolerance to extended hiking.
JP show several unhealthy behaviors, such as brushing teeth only one time daily, not having mammograms, and her continued laxity over having tests performed or her right hip pain. By continuing to only see chiropractors for this and not seeking a physician to run in depth testing, she could end up disabled and unable to participate in her favorite pastime. She has a good understanding of her Psoriasis, as both her daughter and her grandson son have the condition also. She also has several healthy behaviors such as the recent change to her diet, her frequent activity plan, and her minimal medication regimen. JP will benefit from a full physical exam, lab tests and a physical therapy consult.
Ackley, B. J. (2010). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (8th ed.). Mosby. AHA. (2012). Preventing Heart Disease . Retrieved Aug 7, 2012, from American Heart Association: http://www.heart.org/HEARTORG/Conditions/Conditions_UCM_001087_SubHomePage.jsp American Dental Association. (2012). Adults Over 60. Retrieved Sept 26,