Nrs 434
Adult Health History and Examination
ND
Health Assessment and Screening
NRS 434-V
Health History and Examination
LH
Client/Patient Initials: LH Sex: F Age: 47
Occupation: Registered Nurse
Health History/Review of Systems
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”.
ND
Health Assessment and Screening
NRS 434-V
Health History and Examination
LH
Client/Patient Initials: LH Sex: F Age: 47
Occupation: Registered Nurse
Health History/Review of Systems
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”.
References: Carpenito L,J. (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (14th ed.). Wolters,Kluwer. 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). Retrieved Sept 26, 2012, from Mouth Healthy: http://www.mouthhealthy.org/en/adults Cluett, J. (2012). Knee Pain. Retrieved Sept 28, 2012, from About Orthopedics: http://orthopedics.about.com/cs/hipsurgery/a/hippain.htm Jarvis, C. (2012). Physical Examination & Health Assessment (6 ed.). St Louis: Saunders. http://www.webmd.com/pain-management/knee-pain/runners-knee YMCA.net