10/13/2015 @ 1620. KJ; 24 yo; female; Caucasian; nursing student. Vital signs: BP: 120/72 left arm, sitting down; T: 98.7 ̊ - Oral; P: 68 regular radial; R: 16 unlabored; O2 sat: 98 room air; height: 5’ 8”; weight: 160lbs; BMI: 24.3. General Assessment: Well dressed and groomed, no odor; alert and oriented x 4; affect appropriate for the situation, pleasant; no signs of distress. Overall body structure lean, symmetrical and proportional; sitting upright. 6 piercings above her head; no tattoos. Chief Concern: patient states, “I haven’t felt well for 4 days and have been vomiting for the past two days.” Symptom Analysis: Onset: woke up feeling ill on Friday morning, vomiting started Sunday evening. Location: pain generalized across abdomen. Quality:
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Patient’s father died at age 51 of a heart attack. Patient has no siblings. Maternal grandmother died of a heart attack and paternal grandfather died of Alzheimers. Patient doesn’t know health history for paternal grandparents. Psychosocial History: lives alone in an apartment close to school. Patient currently does not work but over the summer worked as a Nursing Assistant at a skill nursing facility. Has annual physicals and mammograms; has never used recreational or street drugs. Drinks 2-4 alcoholic beverages per a week. Has never smoked or chewed tobacco. Patient is a nursing student; goes to school at different times. A typical day includes: waking up with an alarm by 7am on most days, showers, and eats cereals and fruit. Has lunch which usually consists of water and salad. Dinner usual consists of some form of meat and vegetables. Patient walks at least 30 minutes each day. However, would like to exercise more but doesn’t have enough time due to the amount of school work. Studies 5-8 hours a day and goes to bed around 1am. Patient reports she doesn’t get enough sleep. Enjoys walking, hiking, and watching television. Patient is not religious, however, is …show more content…
Has a good support system; friends and boyfriend that live close to her; talks to her parents on the phone daily. Focused assessment- Abdominal: Contour round and symmetrical; light beige skin tone; hair distribution consistent with female pattern; no scars; umbilicus is midline, inverted with no debris or discharge; no visible aortic pulsation; slight respiratory movement; no visible peristaltic
Patient’s father died at age 51 of a heart attack. Patient has no siblings. Maternal grandmother died of a heart attack and paternal grandfather died of Alzheimers. Patient doesn’t know health history for paternal grandparents. Psychosocial History: lives alone in an apartment close to school. Patient currently does not work but over the summer worked as a Nursing Assistant at a skill nursing facility. Has annual physicals and mammograms; has never used recreational or street drugs. Drinks 2-4 alcoholic beverages per a week. Has never smoked or chewed tobacco. Patient is a nursing student; goes to school at different times. A typical day includes: waking up with an alarm by 7am on most days, showers, and eats cereals and fruit. Has lunch which usually consists of water and salad. Dinner usual consists of some form of meat and vegetables. Patient walks at least 30 minutes each day. However, would like to exercise more but doesn’t have enough time due to the amount of school work. Studies 5-8 hours a day and goes to bed around 1am. Patient reports she doesn’t get enough sleep. Enjoys walking, hiking, and watching television. Patient is not religious, however, is …show more content…
Has a good support system; friends and boyfriend that live close to her; talks to her parents on the phone daily. Focused assessment- Abdominal: Contour round and symmetrical; light beige skin tone; hair distribution consistent with female pattern; no scars; umbilicus is midline, inverted with no debris or discharge; no visible aortic pulsation; slight respiratory movement; no visible peristaltic