Adult Health History and Examination
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Neurological System headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, and difficulty swallowing etc., medication): Neurologically JP is intact. Alert ox3 clear speech with no hesitations, c/o headaches and dizziness occasionally, upon arising in the am. She admits being “little stressed to family situations” and rotating shifts (DAYS/NIGHTS). Suggested to seek EAP (Employee Assistance Program) at work Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications: LH has full ROM to neck and head, closes her eyes and able to hold her arms and hands out without swaying. LH takes Motrin 800mg for headaches. Motrin (ibuprofen) is a no steroidal anti-inflammatory drug (NSAID). It works by reducing hormones that cause inflammation and pain in the body. This medicine may also cause serious effects on the stomach or intestines, including bleeding or perforation (forming of a hole).
These conditions can be fatal and can occur without warning while you are taking Motrin, especially in older adults. Nursing Drug Handbook (2013) 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: LH has myopia and astigmatism. She wears glasses for correction and contact lenses for aesthetics, no familial history of glaucoma, last eye exam on Sept 12, with no problems. Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications: LH states “better than average.” “I can’t see, but I sure can hear”. Denies tinnutitis, or being subjected to loud noises. She has had no surgeries or infections. Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications: LH gag reflex intact, oral mucosa moist, pink intact.
Teeth intact, cavities noted on 2 back teeth, last dental exam was Jan2012, with a cavity filled, discussed the need to floss more, she brushes daily and after meals. Reports frequent rhinorrhea and nasal congestion, during the spring and summer. She self-treats this with over the counter Claritin-D 10/200mg LH feels that she has seasonal allergies, she refuses allergy testing. LH states “I do not need to be poked to know I have hay fever”. Reinforced to LH the drug classification and side effects of Claritin D. The decongestant in Claritin-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. Nursing Drug Handbook (2013) 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, and rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications): LH has soft, supple warm skin. LH has old acne scarring over facial area stated “I had really bad pimples when I was younger and used to picked them, but I have not had any issues in years”. LH also has thinning hair “I have had had it for years”. Maternal History of Alopecia and thinning hair, LH mother started losing hair in teens. LH uses Rogaine shampoo 3 times a week. Women experience more dramatic, localized hair thinning, even a noticeable bald spot. This condition is called male pattern baldness, or androgenetic alopecia (AGA), and it is the most common form of hair loss in both men and women. It almost always occurs on the top and sides of the head and above the forehead, and may also involve excessive hair growth on the face and other areas on the body, though the range of severity is wide. WebMD.com. Rogaine dilates blood vessels in the scalp, which may improve hair follicle function and stimulate hair growth.
Rogaine is used to treat male pattern baldness in patients who are experiencing gradually thinning hair on the top of the head. www.drugs.com Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications): LH denies implants, trauma or injury LH stated “I would love saline implants, I breast fed both of my children “She performs self-breast exams in the shower monthly, and her physician exams her yearly for her physical. Her last mammogram was April 2012. Mammogram is a low-dose x-ray exam of the breasts to look for changes that are not normal. The results are recorded on x-ray film or directly into a computer for a doctor called a radiologist to examine. Womenshealth.gov Peripheral Vascular and Lymphatic System (leg pain, cramps, and skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications): LH reports that she does not have leg cramps or pain, but that she does have “varicose veins”.
LH denies use of compression hose. Encourage to use compression hose, when standing and sitting for long periods. 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): LH denies shortness of breath, fatigue or swelling of extremities. LH has a maternal and paternal history of hypertension. LH understands the ramifications of familial history of high blood pressure. Denies chest pain. Hypertension occurs when the blood pressure, or force of blood pushing against the blood vessel walls, gets too high and stays that way. It occurs most often in African-Americans. The top number, or systolic blood pressure, occurs when the heart pumps or contracts. The bottom number, or diastolic blood pressure, occurs when the heart is resting or relaxing. Most health professionals agree that the upper range of normal blood pressure should be 130/80 or less. www.cdc.gov 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): LH denies COPD, asthma, bronchitis. No history of smoking.
Last TB test was October 2012 for job yearly screening. 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): LH had a right knee arthroscopy on January 11, 2013. She has been jogging 3x weekly for the past 18 years. The knee surgery was for normal wear and tear due to running on hard surfaces. LH has full rom on left extremity. LH is currently taking Nucynta 50mg for pain relief. Tapentadol (trade names: Nucynta) is a centrally acting analgesic with a dual mode of action as an agonist of the μ-opioid receptor and as a norepinephrine reuptake inhibitor. It is also an agonist of the σ2 receptor, though the function of this orphan receptor remains controversial. While its analgesic actions have been compared to tramadol and oxycodone, its general potency is somewhere between tramadol and morphine in effectiveness.
It has opioid and nonopioid activity in a single compound. Nursing Drug Handbook (2013). Knee arthroscopy is a minimally invasive surgical procedure in which an examination and sometimes treatment of damage of the interior of a joint is performed using an arthroscopy, a type of endoscopy that is inserted into the joint through a small incision. Arthroscopic procedures can be performed either to evaluate or to treat many orthopedic conditions including torn floating cartilage, torn surface cartilage, ACL reconstruction, and trimming damaged cartilage. 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, and medications): LH denies any issues of digestion; she eats 2 full meals daily (breakfast and dinner) and snacks between, mostly fruits and nuts. LH is 67 inches and 148 lbs. 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): LH denies any urinary frequency, dysuria or polyuria at this time. Physical Examination
(Comprehensive examination of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory assessments): LH is able to smile, smirk and blink without difficulty. Her face is symmetrical with no involuntary movements (i.e. twitching). She able to identify smells and taste without difficulty. 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 trachea and thyroid gland): Trachea is clear, thyroid is midline intact. Lymph nodes are small and non-visible LH’s head is round and is normocephalic, with no tenderness upon palpation. She has dry thinning hair. Eyes (test visual acuity, visual fields, extra ocular muscle function, inspects external eye structures, inspect anterior eyeball structures, inspect ocular fundus): LH has symmetrical black, thinning eyebrows, with evenly place dark brown eyes that appear flat. Her sclera are white and moist, her pupils are PERRLA 3mm. Both conjunctivae are pink, and no ulcers are noted. There is a positive corneal reflex noted. She is able read a Snelling eye chart top line with her glasses on, and then she can read the smallest line. No nystagmus noted. Ears (inspect external structure, otoscopic examination, inspect tympanic membrane, and test hearing acuity): her ear lobes are symmetrical, bean shaped.
The pinna recoils. Small metal balls noted in lobes. Auricles are having a firm cartilage on palpation, with no tenderness. No discharge noted, with small brownish red cerumen noted in left ear, the membrane is flat, and pearly gray in color Nose, Mouth, and Throat (Inspect and palpate the nose, palpates the sinus area, inspect the mouth, inspect the throat): LHs 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 intact no tenderness upon palpation. No Temporomandibular crepitus noted. Gums are pinkish, without bleeding. Receding gums noted on lower front teeth. Dental carries in back teeth and no halitosis. Tongue pink moist intact has no lesions or varicosities. JP is able to move her tongue freely. Gag reflex is intact. Her tonsils were removed at age 4. Her trachea is midline, with no nodules. Her thyroid is not palpable. She has range of full motion in her neck. 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): Skin color is brown, supple and warm. There is a midline scar noted on lower abdomen, well healed and intact. Nails manicured, pink with polish in place. Breasts and Axilla (deferred)
Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses; inspect legs, venous pattern, varicosities, pulses, color, swelling, and lumps): LH legs are warm, intact, green broken veins noted on the back of both legs, intact. Radial pulses are palpable, strong, and equal. R 56, L58Her legs show no venous engorgement. Bilateral pedal pulses 2+, strong. 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.
Apical rate 58 Sinus Bradycardia no ectopy, jugular veins distension noted. Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion; percussion of anterior, lateral and posterior, abnormal breathing sounds): Lung sounds clear bilaterally throughout lung fields 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.
LH is able to counter act gravity and resistance on ROM. Reflexes intact and strong. All extremities can perform full 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 hypoactive. Abdomen soft and flat.The liver cannot be palpated. Tension is smooth and consistent with no muscle guarding. Genitourinary System (deferred)
Cognitive-Perceptual Pattern: LH wears glasses for corrective vision, has long term and short term recall. Learns best by listening, she is able to hear and write without difficulty. LH is often distracted by home situations and stress. LH is experiencing discomfort for her right knee, she using heat packs and pain medication. Nutritional-Metabolic Pattern: LH watches her sodium, fat and sugar intake. She is not dieting; however her goal is to maintain her weight within 5lbs of the target 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: LH is Gravida 2, Para 2 Abortions 0. She has 2 adult sons, and 1 grandson. LH is premenopausal and denies complications except for the occasional “hot flash”. LH is not using any medications “I’m letting it happen naturally”. LH is married this is her 3rd husband, been married for 8 years and is sexually active and monogamous.
Pattern of Elimination: LH reports daily bowel movements, with occasional constipation. She uses prune juice and Metamucil. Pattern of Activity and Exercise: LH was running 3x weekly until the procedure she is currently doing Physical Therapy 2x week for 6 weeks. She lifts hand weights daily. Pattern of Sleep and Rest: LH sleeps 5-6 hours daily without sleep aids. Pattern of Self-Perception and Self-Concept: LH is adjusting to her role as charge nurse at night, maintaining her role as wife, grandmother and mother. LH has 1 brother, who she speaks to weekly and her mother 3x weekly. Both of whom lives in another state. LH states “I feel better than most women my age” Situation (reason for seeking care, patient statements): LH is a 47 year-old African American female. She is 67 inches and 149lbs. She is status postop right knee arthroscopy Right knee discomfort, right knee with ace dressing.
LH discomfort level is 4/10, throbbing when up ambulating. Background (health and family history, recent observations): The patient has a history of right knee pain after jogging Assessment (assessment of health state or problems, nursing diagnosis): VSS= T 36.1, P58, BP 106/58. Patient grimaces upon walking. Gait steady, ambulating with crutches full weight bearing on right knee. No Pedal pulses +2, regular. Pupils are PERRLA, Lung sounds are clear bilaterally throughout lung fields and heart rate is regular 58 SB with S1S2 audible. Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education): education on pain management, hand washing and exercise. Continue with Physical therapy Patient education on the use of anti-thrombotic hose, when standing and walking for long periods. Stretching muscles prior to exercising. Stretching the muscles and tendons that surround the joints to improve flexibility.
Nursing Diagnosis: Impaired Physical Mobility R/T to decrease ROM of right knee 1 week post op. Intervention 1: Educate LH to stop running on hard surfaces or activity immediately and report to the physician if she experiences the following symptoms: new or worsened intensity or increased frequency of discomfort Rationale: Running on hard surfaces causes, the joints and tendons to become worn and loses the synovial fluid around the joint. Patient Outcome: LH will have less discomfort when running.
Intervention 2: LH will continue with physical therapy for resistance exercise training, including abdominal crunch, leg press, leg extension, leg curl, calf presses. Rationale: Six months of resistance exercise greatly increased their aerobic capacity, possibly from increased skeletal muscle strength and flexibility. Conclusion
LH has healthy behaviors regarding physical health. However, she needs to develop better ways to relieve stress, (i.e. speaking with a counselor, reading books, attending church). Also LH needs to improve her sleeping hours, by developing sleep time rituals (i.e. turn off TV, turn off lights, and cover the windows). LH will manage her discomfort, by continuing on pain medication as prescribed, and follow up with surgeon appointments as directed. Suggested LH use local YMCA for water exercise, less tension on the knees. LH will be attending church and bible study to help with coping mechanisms.
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