June 18, 2014
Focus Assessment The purpose of this paper is to document a focused history, physical exam, nursing diagnoses, and nursing process of a case study about a 22-year-old woman that reports as chief complaint : feeling “sick with the flu” for the past 8 days. History of present illness : vomiting several times every day, having difficulty keeping liquids or food down, and has been using more than the recommended dose of antacids in an attempt to calm the nausea. She has become severely dehydrated. After fainting at home, she was taken to a local hospital (Grand Canyon University 2010). Medications: Prozac 20 mg by mouth daily. Multivitamins one tab daily. Tums 1000 mg tabs. 10 tabs in the past 24 hrs for nausea/heartburn. Allergies: Drugs Penicillin. Others: seafood and latex.
Review of Systems
GENERAL: patient presents with no elevated temperature. WNL HEENT: patient presents with no complains about her vision, denies sore throat and earache. No signs and symptoms of congestion are observed. NECK: patient denies pain or discomfort.
CARDIOVASCULAR: denies chest pain and palpitations.
PULMONARY: denies congestion or cough. No shortness of breath. GASTROINTESTINAL: complain of slight abdominal pain with nausea and vomiting. GENITOURINARY: Denies urinary frequency, urgency, hesitancy or dysuria and reports not urinating much in the past few days. MUSCULOSKELETAL: Denies any muscle or joint paint and has no recent trauma. DERMATOLOGIC: Skin is intact with poor skin turgor. No rashes or lesions are present. ENDOCRINE: Recent change in weight of 2 lbs possibly do to dehydration. Denies intensive thirst or excessive urination. HEMATOLOGICAL: last Blood work shows a hemoglobin of 13 gm/dl. Denies bruising easily. NEUROLOGIC: denies headaches, seizures, numbness or tingling. PSYCHIATRIC: There is a history of depression. Present treatment is counseling and medication and patient verbalized positive effects from it.
VITAL SIGNS: T: 98.4 BP: 98/58 Pulse: 86 RR: 24 O2 Sat: 98% at RA Wt: 128 lbs. Ht: 61 inches 1. General appearance: responds adequately. NAD, sitting up in the stretcher, well groomed in street clothing. 2. Head/Eyes/Ears/Nose/Throat: Dry mouth. - PERRLA, EOM intact 3. Neck: WNL.
4. Heart: rapid pulse, Heart rate is regular with no audible murmurs - 5. Lungs/Chest: Clear to auscultation. No cough or wheezing observed. 6. Abdomen: Normal bowel sounds, abdomen soft and slightly tender. 7. Extremities/Back: - equal strength and full ROM in all extremities, no swollen, worm to touch or reddened joints. 8. Neurological – Alert and oriented x 3, Cranial Nerves 2-12 grossly intact. 9. Skin: Poor skin turgor. No rashes observed, skin warm and dry to touch. 10. Lymphatic: No grossly enlarged or inflamed lymph nodes noted during palpation. No lymphadenopathy observed. 11. Rectal exam: not done.
13. Pelvic/GU exam: Not done. Last menstrual period 06/04/2014. Sexually active. Possibility of pregnancy. Not on birth control. Laboratories/Studies:
7.35 – 7.45
40 mm Hg
35-45 mm Hg
95 mm Hg
80-100 mm Hg
Fluid and electrolyte imbalance r/t nausea/vomiting and excessive dose of bicarbonate (metabolic acidosis) Asses for drowsiness, nausea, confusion and breath with fruity odor. Also check for Kussmaul respirations as...
References: Grand Canyon University (2010). Retrieved from: NUR645E.v10RCaseStudy_student.doc
Life nurses (2014) Nursing Assessment. Retrieved from: http://www.lifenurses.com/nursing-assessment/
Pearson (2012) Nursing Care plan: fluid and electrolytes imbalance. Retrieved from:http://wps.prenhall.com/chet_perrin_criticalcare_1/98/25167/6442904.cw/content/
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