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UNIVERSITY OF SOUTH FLORIDACOLLEGE OF NURSINGStudent: U63400058Patient Assessment ToolLONG FORM FUNDAMENTALSAssignment Date: 10/26/2012Agency: TGHPatient Initials: D.S.Age: 60Admission Date: 10/22/12Gender: F Marital Status: MarriedOccupation: NursePrimary Language: EnglishLevel of Education: Associate of Arts in NursingNumber/ages children/siblings: 3 Daughters- 39, 38, 22 & 1-Sisters 58, 2-Brother 56, 48Primary Medical Dx with ICD-10 code: HYPERLINK "" 2012 ICD-10-CM Code T84.9. Unspecified mechanical complication of internal orthopedic device, implant and graftLiving Arrangements: Living home with husbandAdvanced Directive: NoneImmunizations: Flu, PneumoniaCode Status: FULLCulture/ Ethnicity /Nationality: White/CaucasianSurgery Date: Occurred on 10/22/12Procedure: Religion: ChristianType of Insurance: Indeminity30232351841500± 2CC: “I have been having problems with my knee since age 13 when I popped my knee running track.”+3 HPI: The patient is a 60 year old female who complains of a long history of knee pain. Client stated that her most recent onset was after her 7th surgery in December 2011. She describes the pain as constant, sharp and stabbing. She therefore feels discomfort when she turns and ambulate to and from the bathroom and room. Client stated that she felt better when she didn’t move and that taking medications at home and hospital reduces her pain level from a 6 to a 3. She presented to the ER on 10/22/2012. Coagulation assessments were performed before left knee revision surgery. She was placed on narcotic analgesics which includes hydromorphone (Dilaudid), oxycodone (Oxycontin, Oxyir) and oxycodone/acetaminophen (Percocet, Tylox). 2 PMH/PSH Hospitalizations for any medical illness or operationDate Operation or IllnessManagement/Treatment1997Asthma Singulair1990s Multi/x’sPneumoniaVaccine1990s Multi/x’sBronchitisDoesn’t recall/not recorded1990sWheezingAlbuterol (PROVENTIL)1990sHypercholesterimaStated no meds were prescribed1944Hepatitis AIsolation1970Kidney StonesNo treatment 10/2012GERDNone/not recorded09/2012AnemiaNone/not recorded10/2012Discoid LupusNone/not recorded2001Allergic RhinitisZertex D1970MigrainesSumatriptan (MITREX)1990sPONV (Postoperative nausea and vomiting)ProchlorperazinePSH1920Wrist surgery (right)Remove ganglia cyst1990Tubal ligationDoesn’t recall/Not Recorded1993Joint replacement (left knee)Physical Therapy1947-2012Knee surgery (left x 6)Physical Therapy1995Bunionectomy (bilateral)Implantation of screws/ 2 FMHAge (in years)Cause of Death (if applicable)AlcoholismEnvironmental AllergiesAnemiaArthritisAsthmaBleeds EasilyCancerDiabetesGlaucomaGoutHeart Trouble(angina, MI, DVT etc.)HypertensionKidney ProblemsMental Health ProblemsSeizuresStomach UlcersStrokeTumorFather88 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mother77 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Brother56 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sister58 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Grandfather70Pancreatic Cancer FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Grandmother99Old Age FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Daughter39 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comments: 1 immunization HistoryYesNoRoutine childhood vaccinations FORMCHECKBOX FORMCHECKBOX Routine adult vaccinations for military or federal service FORMCHECKBOX FORMCHECKBOX Adult Diphtheria (Date) FORMCHECKBOX FORMCHECKBOX Adult Tetanus (Date) FORMCHECKBOX FORMCHECKBOX Influenza (flu) (Date) FORMCHECKBOX FORMCHECKBOX Pneumococcal (pneumonia) (Date) FORMCHECKBOX FORMCHECKBOX Have you had any other vaccines given for international travel or occupational purposes? Please List FORMCHECKBOX FORMCHECKBOX 1 Allergies or Adverse ReactionsNAME of Causative AgentType of Reaction (describe explicitly)MedicationsActonelHeadache/Kidney StonesAspirinBleedingClonazepamTongue and Throat SwellingFentanylPATCH-cause blistersLyricaHives/ConfusionMorphineHeadacheNSAIDSBleedingPenicillinsHivesSulfa (Sulfonamide Antibiotics)InsomniaTegretol (Carbamazepine)BleedingOther (food, tape, dye, etc.)TapeTurns skin beat red 5 PATHOPHYSIOLOGY: (include APA reference) (include any genetic factors impacting the diagnosis, prognosis or treatment) Degenerative joint disease (DJD) or Osteoarthritis is characterized by progressive erosion of articular cartilage and bone overgrowth at the joint margins. Cartilage integrity requires balance between synthesis and degradation of matrix components. Chondrocytes react to various mechanical and chemical stresses in order to stabilize and restore the tissue. Failures in stabilizing and restoring the tissue lead to cartilage breakdown that may be irreversible. Specific causes of DJD are not known. Aging, obesity and familial tendencies are known risk factors. Other risk factors include joint injuries, bleeding into the joint, joint abnormalities, and excessive joint use, as in certain occupations such as high impact sports, construction work and dance.DJD is a complex disorder combining the effects of multiple genes and environment, but the genetic component may be significant. Identical twins are 5 times more likely to develop DJD in the knee or hip in comparison to non-identical twins.Symptoms of degenerative joint disease generally begin after age 40 and are more common in women than men after 55 years of age. DJD affects all races and ethnicities but is more prevalent in Native Americans and whites than in other populations Women have DJD of the knee joints more frequently than in women but DJD of the hip is more common in men than women. People of Chinese orgin seem to have a lower prevalence of QA. Reference: S. Jandric (2002). Etiology, Pathophysiology and conservative therapy of degenerative rheumatic diseasees Central. Unbound Medicine, Inc (2000-2012) available from central/ub 5 Medications: (Include both prescription and OTC)Name: AcetaminophenConcentration: N/ADosage Amount: 650 mgRoute: OralFrequency: PRNPharmaceutical class : Antipyretics, Nonopoid AnalgesicsHome Hospital X or Both Indication: Mild pain and feverSide effects/Nursing considerations: Anxiety, agitation, headache, fatigue, insomnia, atelectasis, dyspnea, hypertension, hypotension, HEPATOTOXICITY, constipation, liver enzyme, nausea and vomiting. Hypokalemia, renal failure, neutropenia, pancytopenia, pancytopenia, muscle spasms, trismus. Rash, urtricaria. Assess overall status and alcohol usage before administering.Name: AmitriptylineConcentration N/ADosage Amount: 75 mgRoute: OralFrequency: DailyPharmaceutical class: Tricyclic antidepressantsHome Hospital or Both XIndication: DepressionSide effects/Nursing considerations: SUICIDAL THOUGHTS, lethargy, sedation, blurred vision, dry eyes, dry mouth. ARRPHYTHMIAS, TORSADE DE POINTES, hypotension, ECG changes, QT interval prolongation. Assess for suicidal tendencies especially during early therapy.Name: Baclofen (LIORESAL)Concentration: N/ADosage Amount: 10 mgRoute: OralFrequency: DailyPharmaceutical: Home Hospital or Both XIndication: Treatment of reversible spasticitySide effects/Nursing considerations: SEIZURES, dizziness, drowsiness, fatigue, weakness, confusion, depression, headache, insomnia, nasal congestion, tinnitus, edema, hypotension, nausea, constipation, frequency, pruritus, rash, hyperglycemia, weight gain, ataxia, hypersensitivity reactions, sweating.Name: Dextrose 5% and 0.45% NaCI with KCI 20 mEq infusionConcentration N/ADosage Amount 100 mL/hrRoute IntravenousFrequency ContinuousPharmaceutical class: CarbohydratesHome Hospital X or BothIndication: Provides caloriesSide effects/Nursing considerations: Inappropriate insulin secretion, fluid overload, hypokalemia, hypomagnesemia, hypophosphatemia, local pain/irritation at IV site, glycosuria, hyperglycemia.Name Diphenhydramine (BENADRYL)Concentration N/ADosage Amount 25 mgRoute : OralFrequency PRNPharmaceutical class : AntihistaminesHome Hospital X or BothIndication: Release of allergic symptoms caused by histamine release including Anaphylaxis.Side effects/Nursing considerations : Drowsiness, dizziness, headache, paradoxical excitation, blurred vision, tinnitus, hypotension, palpitations, anorexia, dry mouth, constipation, nausea, dysuria, frequency, urinary retention, photosensitivity. Chest tightness, thickened bronchial secretions, wheezing.Name Famotidine (PEPCID) Concentration N/ADosage Amount 20 mgRoute: Oral Frequency DailyPharmaceutical class: Histamine h2 antagonistHome Hospital x or BothIndication: Short-term treatment of active duodenal ulcers and benign gastric ulcersSide effects/Nursing considerations: Confusion, dizziness, drowsiness, hallucinations, headache. ARRHYTHMIAS. Constipation, diarrhea, nausea. Gynecomastia. AGRANULOCYTOSIS, APLASTIC, ANEMIA, neutropenia, thrombocytopenia. Assess for epigastric or abdominal pain and frank or occult blood in stool.Name Fluticasone (Flonase) 50 mcq/Actuation Nasal Spray 1 SprayConcentration N/ADosage Amount 1 SprayRoute NasalFrequency DailyPharmaceutical class: CorticosteroidsHome Hospital or Both XIndication: Maintenance and prophylactic treatment of asthmaSide effects/Nursing considerations: Headache, dizziness, dysphonia, hoarseness, oropharyngeal, fungal infections, nasal stuffiness, rhinorrhea, sinusitis. Bronchospasm, cough, upper , upper respiratory tract infection, wheezing. Diarrhea, adrenal suppression, muscle pain.Name Mupirocin (BACTROBAN) 2% OintmentConcentration N/ADosage Amount 3 Route NasalFrequency DAILYPharmaceutical class: Anti-infectivesHome Hospital x or BothIndication: Treat impetigoSide effects/Nursing considerations: Headache, cough, itching, pharyngitis, rhinitis, upper respiratory tract congestion. Nausea, altered taste. Burning, itching, pain, stinging.Name Oxycodone (OXYCOTIN) Concentration N/ADosage Amount 60 mgRoute Oral Frequency EVERY 12 HOURS Pharmaceutical class: Opioid agonistHome Hospital or Both XIndication: Side effects/Nursing considerations: Confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. Blurred vision, diplopia, miosis, RESPIRATORY DEPRESSION, orthostatic hypotension, constipation, dry mouth, choking, GI, obstruction, nausea, vomiting. Urinary retention. Flushing, sweating. Physical dependence, tolerance.Name Oxycodone (ROXYCODONE) Inmediate Release Tablet 15 mgConcentration N/ADosage Amount 15 mgRoute OralFrequency PRNPharmaceutical class: Opioid agonistHome Hospital X or BothIndication: Moderate to severe painSide effects/Nursing considerations: Confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. Blurred vision, diplopia, miosis, RESPIRATORY DEPRESSION, orthostatic hypotension, constipation, dry mouth, choking, GI, obstruction, nausea, vomiting. Urinary retention. Flushing, sweating. Physical dependence, tolerance.Name Poleythylen Glycol (MIRALAX) Concentration N/ADosage Amount 17 gRoute OralFrequency DAILYPharmaceutical class: OsmoticsHome Hospital X or BothIndication: Treatment of occasional constipationSide effects/Nursing considerations: Uriticaria, abdominal bloating, cramping, flatulence and nausea.Name Senna-Dacusate (SENOKOT-S) Concentration N/ADosage Amount 50 mgRoute OralFrequency NIGHTLYPharmaceutical class: Stimulant laxativesHome Hospital X or BothIndication: Treatment of constipation associated with dry, hard stools and decreased intestinal motility.Side effects/Nursing considerations: Electrolyte imbalances, dehydration, abdominal cramps, nausea, vomiting, diarrhea, rashes. Urine discoloration.Name Vancomycin in D5W 1 Gram/200 m/L PgBk Concentration N/ADosage Amount 1,000 mgRoute IntravenuousFrequency EVERY 12 HOURSPharmaceutical class: anti-infectivesHome Hospital X or BothIndication: Treatment of life threatening infectionsSide effects/Nursing considerations: Ototoxicity, hypotension, nausea, vomiting, nephrotoxicity, rashes, eosinophilia, leukopenia, phlebitis, back and neck pain.Name Warfarin (COUMADIN) Concentration N/ADosage Amount (1 x 5 mg Tablet)Route OralFrequency DAILY Pharmaceutical class: CoumarinsHome Hospital X or BothIndication: Prophylaxis and treatment for venous thrombosis, pulmonary embolism, and atrial fibrillation with embolizationSide effects/Nursing considerations: Cramps, nausea, dermal necrosis, BLEEDING, and fever.Name HYDROmorphone (DILAUDID) PCA 0.2 mg/mlConcentration N/ADosage Amount 50 mL =10 mg of 0.2 mg/mLRoute IntravenuousFrequency CONTINUOUSPharmaceutical class: Opoid AgonistHome Hospital X or BothIndication: Moderate to severe painSide effects/Nursing considerations: Confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. Blurred vision, diplopia, miosis, respiratory depression, hypotension, bradycardia, constipation, dry mouth, nausea, vomiting. Urinary retention. Flushing, sweating. Physical dependence, tolerance.Name Oxycodone (ROXICODONE) Concentration N/ADosage Amount 5-10 mgRoute Intravenuous Frequency CONTINUOUSPharmaceutical class : Opoid agonistHome Hospital X or BothIndication: Moderate to severe painSide effects/Nursing considerations: Confusion, sedation, dizziness, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. Blurred vision, diplopia, miosis, RESPIRATORY DEPRESSION, orthostatic hypotension, constipation, dry mouth, choking, GI, obstruction, nausea, vomiting. Urinary retention. Flushing, sweating. Physical dependence, tolerance.Name Mupirocin (BACTOBAN) 2% OintmentConcentration N/ADosage Amount 10Route TopicalFrequency DAILYPharmaceutical class: Anti-infectivesHome Hospital X or BothIndication: ImpetigoSide effects/Nursing considerations: Headache, cough, itching, pharyngitis, rhinitis, upper respiratory tract congestion. Wash affected area with soap and water and dry thoroughly.Name :Citrizine-pseudoephedrine (ZYRTEC-D)Concentration N/ADosage Amount 5-120 mgRoute OralFrequency Every 12 hoursPharmaceutical class: PiperazinesHome X Hospital or BothIndication: Seasonal and perennial allergic rhinitis.Side effects/Nursing considerations: Dizziness, drowsiness, fatigue. Pharyngitis, dry mouth.Name :Omeprazole (PRILOSEC)Concentration N/ADosage Amount 20 mgRoute OralFrequency Every 12 hoursPharmaceutical class: Proton pump inhibitorsHome X Hospital or BothIndication: GERDSide effects/Nursing considerations: Dizziness, drowsiness, fatigue, headache, weakness. Chest pain, abdominal pain, acid regurgitation, constipation, diarrhea, flatulence, nausea, vomiting, hypomagnesemia, itching, rash. Bone fracture and allergic reactions.Name : Procholorperazine (COMPAZINE)Concentration N/ADosage Amount 10 mgRoute OralFrequency Every 6 hoursPharmaceutical class: PhenothiazinesHome X Hospital or BothIndication: Manage nausea vomiting, anxiety, psychosesSide effects/Nursing considerations: NEUROLEPTIC MALIGNANT SYNDROME, extrapyramidal reactions, sedation, tardive dyskinesia. Blurred vision, dry eyes, lens opacities. ECG changes, hypotension, tachycardia. Constipation, dry mouth, anorexia, drug induced hepatitis, ileus. Pink or reddish-brown discoloration of urine, urinary retention. Photosensitivity, pigment changes and rashes. Galactorrhea.Name :Sumatriptan (IMITREX)Concentration N/ADosage Amount 100 mgRoute OralFrequency PRNPharmaceutical class: Five ht1 agonistHome X Hospital or BothIndication: Acute treatment of migraine attacks, cluster heachache episodes.Side effects/Nursing considerations: Dizziness, vertigo, anxiety, drowsiness, fatigue, feeling of heaviness, feeling of tightness, headache, malaise, strange feelings, tight feeling in head, weakness. Alteration in vision, nasal sinus discomfort. /mi, angina, chest pressure, chest tightness, coronary vasospasm, ECG changes, transient hypertension. Abdominal discomfort, dysphagia. 4 NUTRITION: (Include: type of diet, 24 HR average home diet, 24 HR diet recall, your nutritional analysis)Diet ordered in hospital? Client is on a regular diet in the hospital but her appetite is low. Therefore, she only consumes clear liquids such as water, coffee and juice. Client may also have a sherbet and fruits. Analysis of home diet (Compare to food pyramid and Consider co-morbidities and cultural considerations):Diet pt follows at home?Breakfast: Patient stated that she usually eats toast and cereal.Client needs to try to eat more whole grain cereals/oatmeal and adding fruit with her cereal such as a banana. She should also try drinking orange juice with a high-fiber muffin. A glass of milk to with her toast (rye or pumpernickel) to continue her buildup of calcium considering her history of joint weakness. Lunch: Patient usually skips lunch but if she does eat For lunch she may want to consider eating a salad with bake chicken and also adding raw fruits with her sandwich. Fruits and vegetables contain fiber and antioxidants to promote a healthy system and prevention against disease.she will make a sandwich.Dinner: Patient usually eats spaghetti, lasagna, bean soup, chicken, red meat, fish, rice and ice tea.Client may want to cut down on eating spaghetti and lasagna by adding more vegetables and greens to her plate. She also may want to, eat more bake her chicken that are boneless and skinless. She should substitute white rice with whole grain/brown rice. She should also try to drink fruit juice and adding more water to her diet.Snacks: Patient consumes yogurt as a snackPatient should also try applesauce, grapes, peach, and blueberries, rasberries and strawberries avoiding sugar filled fatty snacks. She can also snack on whole grain crackers with cheddar or swiss cheese. 5 DEVELOPMENTAL CONSIDERATIONS:Erikson’s stage of psychosocial development: FORMCHECKBOX Trust vs. FORMCHECKBOX Mistrust FORMCHECKBOX Autonomy vs. FORMCHECKBOX Doubt & Shame FORMCHECKBOX Initiative vs. FORMCHECKBOX Guilt FORMCHECKBOX Industry vs. FORMCHECKBOX Inferiority FORMCHECKBOX Identity vs. FORMCHECKBOX Role Confusion/Diffusion FORMCHECKBOX Intimacy vs. FORMCHECKBOX Isolation FORMCHECKBOX Generativity vs. FORMCHECKBOX Self absorption/Stagnation FORMCHECKBOX Ego Integrity vs. FORMCHECKBOX DespairGive the textbook definition of both parts of Erickson’s developmental stage for your patient’s age group:“Generativity versus stagnation is the seventh stage of Erik Erikson’stheory of psychosocial development. This stage takes place during middle adulthood between the ages of approximately 40 and 65. During this time, adults strive to create or nurture things that will outlast them; often by having children or contributing to positive changes that benefits other people.Contributing to society and doing things to benefit future generations are important needs at the generativity versus stagnation stage of development. Generativity refers to "making your mark" on the world, through caring for others, creating things and accomplishing things that make the world a better place.Stagnation refers to the failure to find a way to contribute. These individuals may feel disconnected or uninvolved with their community and with society as a whole.Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail to attain this skill will feel unproductive and uninvolved in the world”Describe the characteristics that the patient exhibits that led you to your determination: D.S is at generativity. She is very involved as a mother and grandmother. Proving nurture and care as needed. She is very understanding and supportive of her 38 year old daughter’s choice to not have children, as she and her husband are dedicated to running. D.S therefore, encourages everyone to make choices that will make them happy. As a hospice nurse she is patient and kind attending to her client and their family wishes. She strives to keep everyone happy. Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: Despite her 8 surgeries she has a positive attitude and a great sense of humor. Her dedication to her job is admirable as she has ever intention to go back to work as soon as possible. She is aware of the wear and tear of her knee joints over the years and is accepting to the fact that she may have to go through surgery again for the wear and tear of her right knee. She stated that she is also aware that she needs to improve the care of herself to keep up with the demands of caring for others.+3Cultural Assessment: What do you think is the cause of your illness? “My kneeing getting worn out”What does your illness mean to you? “I guess I won’t be called Gump or Chester anymore”+3 Sexuality Assessment: (the following prompts may help to guide your discussion)Consider beginning with:? “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.? All of these questions are confidential and protected in your medical record”Have you ever been sexually active?_Yes___________________________________________________________________ Do you prefer women, men or both genders? ________Men_____________________________________________________Are you aware of ever having a sexually transmitted infection??___No____________________________________________ Have you or a partner ever had an abnormal pap smear?_I haven’t had a pap smear in 8 years_______________________________________________ Have you or your partner received the Gardasil (HPV) vaccination? ____No Are you currently sexually active??? ______yes_____________________When sexually active, what measures do you take to prevent acquiring a sexually transmitted disease or an unintended pregnancy?? _____________monogamy_____________________How long have you been with?your current partner?_over 40 years____________________________________________________Have any medical or surgical conditions changed your ability to have sexual activity?? ________No___________________Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? No+3 Smoking, Chemical use, Occupational/Environmental Exposures:1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes X No If so, what? How much?For how many years? 10Cigarettes0.5 packs/day(age 14 thru 24 )If applicable, when did the patient quit? 10/17/1988Does anyone in the patient’s household smoke tobacco? If so, what, and how much? NOHas the patient ever tried to quit? Yes2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No X What?How much?For how many years?(age thru ) If applicable, when did the patient quit?N/A3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No X If so, what? N/AHow much? N/AFor how many years?(age thru ) N/A Is the patient currently using these drugs? Yes No XIf not, when did he/she quit?4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks: No+10 REVIEW OF SYSTEMS: (Include health promotion/maintenance activities)General Overall Health Status: Patient mentioned that she has gained a few pounds over the years of which she would like to lose. She hopes that the surgery was successful and that physical therapy will strengthen her joints in order to add exercise to her routine.Integumentary: Patient stated that her skin with is easily bruised bleeds easily. She however, denies any pruitis, hives or new rashes. Her nails are clean. She showers once to two times daily.HEENT: Has a history head injury from an accident and severe migraines. Sometimes has difficulty hearing but denies any ear pain, ear infections, tinnitus or discharge from ears.. Patient has had glaucoma surgery and sometimes experience difficulty seeing which her optometrist stated may be attributed to her medications. She denies diplopia, cataracts. redness, swelling or discharge from her eyes. She has a history of nose bleeds, post-nasal drip, and oral/pharynhgeal infection. She denies neck pain Denies any throat pain and frequent sore throat. She brushes 3 x’s a day and goes to the dentist twice a year. Denies any bleeding gums or mouth lesionsRespiratory: Patient stated difficulty breathing, asthma, bronchitis, and pneumonia. Denies ever receiving a CXR. Denies emphesema, Tuberculosis and environmental allergies.Cardiovascular: Denies hypertension chest pain/angina, myocardial infarction, CAD/PVD, CHF, Murmur, thrombus, rheumatic fever, myocarditis and arrhythmias. Admits to hyperlipidemia. Her last EKG was September 2012.10 REVIEW OF SYSTEMS: (continued)GI: Patient denies any abdominal pain, nausea, vomiting, diarrhea, indigestion, hemorrhoids, pancreatitis, colitis, diverticulitis, appendicitis, cholecystitis and gastritis. She has a history of constipation, GERD, blood in stool and hepatitis. She has never had a colonoscopy.GU: Patient denies any polyuria or any dysuria. She has had nocturia, hematuria and kidney stones. She urinates around 4 x’s a day.Musculoskeletal: She has a history of injury/fracture, weakness and pain. Denies osteomyelitis and gout.Neurological: Patient denies any numbness, weakness or parenthesias Denies andEndocrine: Patient is anemic, bleeds easily, and bruises easily. Denies cancer and blood transfusion.Hematologic: Denies hot and cold intolerance.+10 PHYSICAL EXAMINATION:Orientation and level of Consciousness:General Survey: Patient is a well-developed 60 year old white female who is a little overweight according to her standards. She presented with mobility distress due to recent knee surgery.Height: 5’8”Weight: 185 BMI:Pain: (0-10) 6BloodPressure: 162/82Temperature: 99.12548890-32385000Pulse: 18(route taken?) OralRespirationsSpO2: 95%On Room Air or O2:Overall Appearance: [Dress/grooming/physical handicaps/eye contact]Patient was sitting erect in chair with minor pain in knee and limited movements. Patient was clean, hair combed, dress appropriate for setting and temperature, maintains eye contact when speaking, and no obvioushandicaps were stated or observed.Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]Patient was appropriate, and cooperative with periods of restlessness from pain medications.Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other] Patient speech was clear with appropriate pace.Mood and Affect: [e.g.: appropriate/apathetic/bizarre/agitated/other]Patient mood was appropriate.Integumentary: Skin was warm to the touch. No clubbing noted. Capillary refill less than 3seconds and skin turgor was good. Client she presented with redness on chest and hands whichstated was normal. IV site was infiltrated so there was some swelling. Hair distribution was even with no alopecia.HEENT: Head is normocephalic and atraumatic. Face is symmetrical with no weakness or involuntary movements. Pupils are equal, round and reactive to light. The conjunctivae are clear, with white sclera and no lesions. There was no ear pain with palpations. Whispered words heard bilaterally. Neck has full range of motion. No thyromegaly or LAD present. Trachea is midline. Carotid and temporal arteries are 2+ with no bruits bilaterally. Nose is deformed due to a deviated septum. Nares are patent and with pink mucosa. All teeth are present and mouth is pink mucosa with no lesions or masses, Tongue protrudes midline.. Throat has pink mucosa with no lesions present. Uvula raises midline and gag reflex is present. 8 Nursing Diagnoses(actual and potential - listed in order of priority)1. Chronic pain related to chronic physical disability as evidence by patient verbalizing a pain level of 6 out of 10 and using a walker to assist with ambulation. ................
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