*NURSING > SHADOW HEALTH > Shadow Health Assignment Tina | 100% score | 8 pages (All)

Shadow Health Assignment Tina | 100% score | 8 pages

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Student Documentation Model Documentation She reports the scrape and pain getting progressively worse and constant in the last few days. She reports the area as red, puffy, and has pus with off whi... te discharge. The pain is centered around the scrape but her whole right foot feels some pain. The pain is described as throbbing and sharp when bearing weight. The pain worsens when she bears weight on her right foot and alleviates with Tramadol. She rated her pain symptoms as 7 out of 10 upon evaluation. She reports fever up to 102 degrees last night and did not take any medication for the fever. She has been doing wound care in the morning and night and uses Neosporin and bandage to protect the wound. She is concerned about the wound and the pain affects her attendance at work. Medications 1. Tramadol 50 mg TID, Last dose 2 tablets priorto arrival. 2. Proventil inhaler 90 micrograms, 2-3 puffs, 2-3 times a week and as needed. Last dose was 3 days ago when she was at cousin's house who had cats. 3. Tylenol 500mg for headache, usually 1-2 tablets at night before bed. Last dose 2 tabs prior to arrival. 4. Advil 200 mg for cramps takes up to three times a day. Last dose was 3 weeks ago. 5. Metformin, unknown dosage and frequency, last taken 3 years ago. Stopped taking because she felt sick and gassy. N/A Allergies 1. Cats - difficulty breathings, sneezing itchy eyes 2. Penicillinas a child, rash, hives 3. Dust- asthma attack N/A Medical History 1. Asthma, diagnosed as a child at about 2.5 years old. 2. Diabetes, type 2, diagnosed 4 years ago. Uncontrolled. She took metformin when first diagnosed but stopped 3 years ago and just watches her diet and avoids sweets. Last lab test for diabetes was 6 months after diagnosed. Denies any surgical history. N/A Health Maintenance Miss Jones' last visit to her primary doctor for a physical exam was about two years ago. Her last dental check up was a few years ago. Her vision was last tested when she was a kid. Her last pap smear was 4 years ago. Denies exercising, She denies going to the gym. She states she is up on her feet all the time at work and considers that her exercise. [Show More]

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