*NURSING > STUDY GUIDE > Chamberlain College of Nursing NR 511 Week 6 (All)

Chamberlain College of Nursing NR 511 Week 6

Document Content and Description Below

Michael S: SUBJECTIVE DATA Chief Complaint (CC): “unusually tired” History of present illness (HPI): A few weeks ago came down with the cold. Everyone in the family has been sick. Increased ti ... redness over that time. Lack of appetite and has lost weight. Always thirsty and has wet the bed last week. Past Medical History (PMH): Age 10. Mother reports general health as good: no childhood or chronic illnesses. Surgeries: none. Hospitalizations: none. Immunizations: UTD: allergies: Penicillin, gets a rash no ETOH, tobacco, illicit drugs. Sleeping 8-10 hours a night. Medications: daily multivitamin Family History (FH): Parents and siblings are in good health, Maternal grandmother: HTN and hyperlipidemia. Maternal grandfather: HTN and hyperlipidemia. Paternal grandparents deceased: Paternal grandmother: brain Ca, Paternal grandfather: leukemia Social History(SH): Good student, oldest of four children. Lives with parents, grandparents and siblings. Has 2 dogs and a cat. Review of Systems (ROS). General: (-) fever, (-) chills, (+) fatigue (-) nausea, (-) vomiting Ears: (-) pain Nose: (-)nasal congestion, (-) discharge Cardiovascular: (-) chest pain, (-) palpitation, (-) dizziness Respiratory: (-) Shortness of breath, (-)wheezes Gastrointestinal: (-) heartburn, (-) indigestion Lymphatics: (-) swelling 0: OBJECTIVE DATA Constitutional: alert, oriented and cooperative VS: Height: 48 inches weight 78 pounds BP 110/70 T 98.2 P 65 R 16.BMI: 23.8 General: Alert and cooperative, appears tired and distracted. HEENT: head normocephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Ears: Tympanic membranes gray and intact This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:32:41 GMT -05:00 https://www.coursehero.com/file/23906554/NR511-Week6/ This study resource was shared via CourseHero.comwith light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses nontender to palpation.Throat: Oropharynx dry, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and S2 noted, RRR, no murmurs, noted. PMI at 5th ICS. Lungs clear to auscultation bilaterally. Respirations unlabored. Skin: color is pale pink, no cyanosis or pallor. Skin cool, dry and intact. Poor turgor. No moles or skin changes [Show More]

Last updated: 3 years ago

Preview 1 out of 6 pages

Buy Now

Instant download

We Accept: