Betty’s Nursing Assessment

Betty’s Nursing Assessment

V/S 132/69 T99.7t P96 R22 Ht. 5’2” Wt. 262lbs

Pt came in today reporting having a sore throat with notable coughing and sneezing. Initial assessment shows notable cloudiness/glaucoma to both eyes r/t Hx of DM II. Betty is very hard of hearing and has 2 hearing aids that she does not wear because she states they are uncomfortable in her ears. This pt is edentulous with notable redness and irritation to the back of her throat. She states she has been taking her Cetirizine as prescribed by her primary care physician. Bilateral Lung sounds are noted to be congested with some wheezing noted to the lower lobes upon expiration. Her respirations are even and unlabored at this time but states she does have SOB upon exertion. Her cough is non-productive with thin whitish sputum noted upon expectoration into a tissue. Positive peripheral pulses palpable times 4 extremities. +1 non-pitting edema noted to Bilateral feet. Stage II pressure ulcer noted to her right heel with a mepilex dressing in place. No drainage noted at this time. Dated 10/23/18. Pt states she goes to the wound clinic twice a week for treatment. Upon auscultation of the pt’s heart sounds it is noted by this nurse that she has a notable bigeminy rhythm(2 beats and a pause). Pt states she has a Hx of cardiac arrhythmia and is to be assessed for a pacemaker placement by her cardiologist next month. Abdomen soft and rounded without any pain or discomfort noted upon palpation of her abdomen. Positive bowel sounds noted times 4 quadrants. States her last BM was this AM prior to her visit. She is continent of the bowel but has some urinary incontinence and wears a depend d/t urinary frequency and urgency. The pt is non-compliant with her dietary orders in relation to her DM II, she states she enjoys cooking and eating too much to change that now. Encouraged the pt that she can make minor changes to her diet and still enjoy her meals. The pt has a Hx of arthritic pain and takes Norco 5/325 mg q4h prn as prescribed by her primary care physician. She states most of her joint pain is in her left knee and has an appointment with her surgeon to be evaluated for a total knee replacement. She currently receives cortisone injections every 3 months to the left knee and states she feels relief after each injection which lasts approximately 2 weeks then the pain returns. Her current level of pain was stated to be 8/10 at this time. Pt’s skin is warm and dry with multiple purplish bruises noted to her right arm and shoulder region. Her right wrist is in a cast and she states she fell down the stairs 3 days prior to this visit and was treated at the local ER. According to the notes she sustained a spiral fracture which may be indicative of an abusive type of physical injury. The pt states that her husband occasionally gets frustrated with her because she can’t keep the house clean as well as she used to prior to her getting sick.

Disclaimer: This assessment was created in response to a question on an assignment, the patient depicted in this post is not a real person.