NURSING > EXAM > NURS 6512 Week 4 Digital Clinical Experiences Notes 2020 – Walden University | NURS6512 Week 4 Dig (All)

NURS 6512 Week 4 Digital Clinical Experiences Notes 2020 – Walden University | NURS6512 Week 4 Digital Clinical Experiences Notes 2020

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NURS 6512 Week 4 Digital Clinical Experiences Notes 2020 – Walden University Ms. Tina Jones is a 28-year-old non-married African American female who presents to her primary care to receive further care for a right foot non-healing scrape. Patient is alert and oriented. Patient maintains appropriate eye contact, with normal, non-slurred speech. Ms. Jones is the primary source of her medical history during initial interview. - - - - - - - - - - - - - -- - Ms. Jones reports that one week ago she was walking down the stairs barefoot, when she tripped and scraped her foot. Patient received medical attention in the emergency room. During her emergency department visit, patient had X-ray completed that were negative, and given Tramadol 50mg PO for pain. Patient reports to cleaning wound twice a day with soap, and water; and dressing wound with a bandage. Patient also used peroxide if scrape appeared irritated. Patient explains weight-bearing movement causes pain to radiate to right ankle. Patient describes the pain as throbbing and sharp with weight bearing. Patient is only able to wear flip-flops and slip-ons. Patient has a current pain level of 7 out of 10 after taking Tramadol 100mg PO at 8:30am. Patient reports foot is red, swollen (ball of foot), with whitish pus drainage around scrape. She reports having a fever of 102 degrees Fahrenheit last night, denies taking any medications for fever. - - - - - - - -- - - - - - - - - - • HEAD- normocephalic, patient reports occasional headaches (once a week), denies hair loss • EYES- Patient eye colors are brown, bilateral pupils are 3mm, pupils are normal and reactive to light, bilateral sclera are white and appears without abnormalities, Ms. Jones reports blurry vision while reading and studying. Patient denies using glasses or contacts. • EARS- patient denies difficulty with hearing, pain and drainage. • NOSE- nose appears symmetrical. Patient reports runny nose with cats and dust. No other further issues. • THROAT- denies issues with neck. Patient reports "crick in neck when reading." • NEURO- alert and oriented, clear speech, denies history of syncope • CARDIOVASCULAR- heart rate 86bpm, denies chest pain, and any issues with heart. Patient only states edema on the ball of her right foot. • RESPIRATORY- respiratory rate 19, denies shortness of breath, or difficulty breathing INTEGUMENTARY- skin not intact due to right foot open wound. • GASTROINTESTINAL- patient denies nausea, vomiting, last bowel movement was last night. Increase in appetite. Unintentional weight loss (10lb in one month). • GENITOURINARY- no burning or discomfort with urination. frequent urination, last menstrual period 3 weeks ago • MUSCULOSKELETAL- normal range of motion of joints

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