Physical Assessment 1 Running Head: PHYSICAL ASSESSMENT 8 PHYSICAL ASSESSMENT Physical Assessment Stratford University NSG 330

Physical Assessment 1
Running Head: PHYSICAL ASSESSMENT

8
PHYSICAL ASSESSMENT

Physical Assessment
Stratford University
NSG 330

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Physical Assessment 1
Running Head: PHYSICAL ASSESSMENT

8
PHYSICAL ASSESSMENT

Physical Assessment
Stratford University
NSG 330

General Survey

Patient (Betty White) is a 61-year-old female who appears stated age. Patients level of consciousness is rated as alert and oriented times 4 (A&Ox4). She is alert and oriented to person, place, time and situation. Her skin color is white. Nutritional status is bad. Patient is overweight. Posture and position are good as she is sitting in the chair comfortably erect with no slouching. No obvious physical deformities are present. Mobility and gait are good. Patient walked to chair with no problems and no assistance. No assistive devices are used. Normal range of motion (ROM) throughout. Contractures of right hand, with resistance to manual spreading/straightening of fingers. No involuntary movement noted. Patient is able to rise from a seated position easily. Patients facial expression is smiling/happy. Mood is relaxed. Affect is broad (normal). Speech is good. Articulation is clear and distinct. Speech pattern is normal. Content is appropriate for visit. Patient wears hearing aids but hears well with them. Personal hygiene is good. No foul odor noted. Overall, patients’ general appearance is good, except the concern of obesity.

Measurements

Patients weight is 145 lbs. (65.91 kg.) Patients height is 59 is inches. Patient is overweight with a BMI (Body Mass Index) of 29.28. Waist circumference is 42 inches. Patient has 20/20 vision, tested using the Snellen eye chart. Temperature: 97.0 F. (Oral). Pulse: 90. Respiratory rate: 18/ min., unlabored. Oxygen Saturation: 96% (Room Air). Blood pressure (190/100 mm Hg right arm, sitting). Blood pressure is elevated; patient has history of hypertension. All other vital signs are within normal range.

Head to Toe Examination

The general appearance of the patient is; overweight woman in no acute distress, sitting comfortably in chair.

Skin: Uniformly tan-pink in color. Warm to touch. No rashes/scars, lesions, birthmarks, edema. Dry skin noted on lower legs bilaterally.

Hair: Normal distribution and texture. No lesions noted on scalp.

Nails: Good shape, contour, consistency. No clubbing, biting or discoloration.

Head: No lesions, lumps, scaling, parasites or tenderness. Face is symmetric with no weakness or involuntary movement.

Eyes: Tested with PERRLA (pupils equal, round, reactive to light, accommodating). No abnormalities noted. EOMI (Extraocular movements intact); no nystagmus. No ptosis, lid lag, discharge or crusting. Corneal light reflex is symmetric; no strabismus. Conjunctivae clear. Sclera clear. 20/20 vision in both eyes (R&L); tested with Snellen eye chart.

Ears: Pinna; no mass, lesions, scaling, discharge, or tenderness to palpation. Cerumen (earwax) obstructing view of temporal membranes bilaterally. Whispered words heard bilaterally. Wears hearing aids.

Nose: Nares patent, without any discharge. Septum midline. No sinus tenderness.

Mouth: Mucosa and gingivae pink; no lesions or bleeding. Tonsils 1+. Gag reflex present. No abnormalities noted.

Neck: Neck supple with full ROM (range of motion). Trachea midline. No thyromegaly. No carotid bruits. Pulses are 2+ bilaterally.

Lymph nodes: No lymphadenopathy present (cervical, axillary and inguinal).

Spine and Back: Normal spinal profile. No tenderness over spine.

Cardiovascular: RRR (Regular rate and rhythm). Normal S1, S2 heart sounds. No murmurs, rubs, gallops. No prominent neck veins or JVD noted. Pulses are 2+ bilaterally (radial, femoral, dorsalis pedis).

Lungs: Chest wall motion symmetric with no accessory muscle use. Resonant to percussion. No wheezes or rhonchi heard.

Abdomen: Soft, nontender, nondistended with active bowel sounds in all four quadrants. Liver width at 10 cm. to percussion along midclavicular line, nonpalpable. Spleen and kidney also nonpalpable. Rectal examination deferred due to lack of gastrointestinal associated complaints. No history or symptoms noted that lead to needing rectal examination done. May be performed later if patient complains of pain/numbness/tingling or certain medication is needed for patient.

Inguinal area: No abnormalities noted in either groin or inguinal nodes.

Extremities: No cyanosis, clubbing or edema. No varicose veins present in lower extremities.

Musculoskeletal: Left side ROM (range of motion) is normal. Right side ROM is slightly decreased. Contractures of right hand, with resistance to manual spreading/ straightening of fingers. No joint swelling or tenderness noted.

Neurological: Alert and Oriented to person, place, time and situation. Slowed mentation but responds with normal speech. No dysarthria, no dysphasia. Cranial nerves II through XII intact. Gait is normal.

Assessment and Plan

Patient is a 61-year-old female with history of CVA (Cerebrovascular accident), HTN (Hypertension), seizure, cocaine abuse and medication noncompliance. Patient presents with increased right sided weakness and slowed mentation. These symptoms are concerning for TIA (Transient ischemic attack) or CVA (Cerebrovascular attack). Other possible diagnosis includes seizure, hypertensive emergency, or intoxication/withdrawal of drugs. Patient has history of seizures. However, patients last seizure was 4.5 years ago and she states that the symptoms she is having now are nothing like the symptoms she has had when having a seizure. She has history of hypertension and noncompliance with the medications prescribed for it. Her elevated blood pressure is probably due to it being chronically high but it could also be elevated due to acutely increased intracranial pressure. She has no complaints of a headache, changes in vision or nausea/vomiting. Patient also has a history of drug abuse which could have contributed to the recent symptoms that the patient had through mechanisms of cerebral ischemia via vasoconstriction. However, the presentation would be very atypical for acute intoxication or withdrawal.

Plan:
Weakness and slowed mentation: CT shows infarct of indeterminate age which could be old and correspond with old MRI findings. It is more likely that this patient had a TIA due to symptoms resolving in a short time frame. For this problem, we are going to:
1. Admit to telemetry unit to monitor the heart.
2. Obtain an MRI to assess the brain infarcts seen in the CT.
3. Neurologic checks done Q2 (every 2) hours.
4. NPO until swallow evaluation done to make sure no issues.
5. PT/OT consults to assess if patient needs any additional help ambulating. Patient seems to be okay, but we still want to consult to make sure.
Hypertension: Patient has ongoing history of uncontrolled hypertension with noncompliance to medication. For this problem, we are going to:
1. Start patient on Lisinopril 25 mg PO (by mouth) every day. Patient is not to have beta blocker due to contraindications with cocaine use.
2. Add Labetalol Q3hr. PRN (Every 3 hours, as needed) if blood pressure >180.
Diabetes Mellitus: Patient previously controlled diet. Patient now does not control diet and is noncompliant with medications.
1. Patient started on ADA (American Diabetes Association) diet (low carbohydrates, high protein).
2. HgbA1C ordered to assess recent glycemic control.
3. Check blood sugar levels before each meal. Give 2 units of Novalog for every 50 above glucose of 110.
Nursing Diagnosis:
(Hypertension) Risk for Decreased Cardiac Output Related to Vasoconstriction.
Interventions:
1. Administer medications as needed. Patient is to be on Lisinopril 25 mg PO Qday as well as Labetolol Q3hr. PRN.
2. Monitor and record blood pressure. Measure in both arms for accuracy.
3. Not dependent and general edema (May indicate heart failure, renal or vascular impairment).
(Diabetes Mellitus) Risk for unstable blood glucose.
Interventions:
1. Assess blood glucose level before meals and at bedtime.
2. Assess for signs of hyperglycemia (increased thirst, hunger, urination, fatigue, blurred vision, etc.)
3. Teach patient how to perform home glucose monitoring.

SOAP Note

S (Subjective): Patient reports increasing right sided weakness.

O (Objective):

Patients Vital signs are as follows:

Temperature: 97.0 F. (Oral).
Pulse: 90.
Respiratory rate: 18/ min., unlabored.
Oxygen Saturation: 96% (Room Air).
Blood pressure (190/100 mm Hg right arm, sitting).

During the head to toe examination, abnormalities found were right sided weakness, contractures of the right hand, with resistance to manual spreading/ straightening of fingers, cerumen (earwax) obstructing view of temporal membranes bilaterally, and patient with slowed mentation but responding with normal speech. All other findings were normal.
Other things found to note are patient is overweight, noncompliant with medications, has diabetes and abuses drugs (cocaine).
MRI confirmed that patient had TIA.

A (Assessment): Risk for Decreased Cardiac Output Related to Vasoconstriction.

P (Plan): Patient will continue to work with OT/PT on strengthening the right side of the body; exercises will get longer each day to see what patient can tolerate. Patient will continue to take medications. Prior to discharge, patient will be educated on medication compliance, drug abuse and symptoms to come back into the hospital for if further problems.

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