Running head: PHYSICAL EXAMINATION (PE) WRITTEN DOCUMENTATION Nursing 200: Complete Physical Examination (PE) Written Documentation Indiana State University College of Nursing‚ Health‚ and Human Services Nursing 200: Complete Physical Examination (PE) Written Documentation The format for this paper is based on : Jarvis (2008). Examiner: ‚ SN ISU Date: 4/12/09 Patient: S.C. Age: 20 Occupation: Full-time nursing student taking 14 hours Language spoken: English Gender:
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offers a wide variety of preventative programs * 33‚000 medical facilities‚ 42 licensed hospitals‚ and 2000 healthcare providers * Readiness for enhanced knowledge r/t increased incidence of diabetes aeb decrease in sedentary lifestyle * Risk for post-trauma syndrome r/t homicide deaths aeb increase in homicide deathsRecommendations: * Educate on use of sunscreen products‚ self-examinations‚ and importance of preventative health care services. * Encourage and educate on the importance of
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Falls‚ risk for r/t diminished mental status aeb fractured R wrist‚ contusions on L knee and forehead‚ unsteady gait‚ “He’s fallen 3 or 4 times now but I don’t want to take away his independence so he lives alone at home”. “My dad often forgets words in mid sentence and will also misplace many of his personal items.” * Activity intolerance r/t hx of CVA aeb limited ROM of R arm. * Incontinence‚ urinary r/t hx of dementia‚ impaired mobility aeb “My dad cannot get to the bathroom in time and
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Exchange R/T STG: 3/17/2014 throughout shift 1. Auscultate breath sounds 1. Abnormal breathing STG: PT O2 saturation on admission abnormal breathing AEB PT will maintain O2 saturation noting areas of decreased sounds are indicative was 87%. Measured at 1602 with a Objective: use of wall oxygen of 95 or higher AEB breathing sounds of numerous problems reading of 100 and measured again administered at 2L via nasal Objective: Consistent O2 and must be
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with a sore throat‚ nasal congestion‚ and has diagnosis of cold. Parents are concerned that the child is not on an antibiotic. Priority NANDA: Deficit Knowledge r/t sore throat and nasal congestion aeb parents requesting ABX for treatment. (note: I am kind of unsure of this dx or if I did the r/t and aeb for it right if someone has insight and could help explain it better on how to word it) Outcome is to educate the parents /parent on the signs and symptoms of a cold and the medication that can be
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Thuy Huynh November 16‚ 2012 Mental Status Exam 1) Appearance (unkempt‚ unclean‚ clothing disheveled‚ atypical clothing‚ well-groomed‚ drab‚ meticulous‚ obese‚ underweight‚ etc.) -clothing were disheveled‚ unshaven-ed beard‚ unclean‚ unkempt attire 2) Attitude (resistive‚ cooperative‚ complacent‚ detached‚ resentful‚ suspicious‚ uncooperative‚ overly compliant‚ provocative‚ other symptom) -detached from surrounding environment‚ seemed to be on guard at all times
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the same line‚ like those in a segment‚ are never equidistant (an equal distance) from a single point. A circle is a simple shape of Euclidean geometry consisting of those points in a plane which are the same distance from a given point called the centre. The common distance of the points of a circle from its center is called its radius. Circles are simple closed curves which divide the plane into two regions‚ an interior and an exterior. In everyday use‚ the term "circle" may be used interchangeably
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Nursing Diagnosis 1. Acute pain R/T: inflammation and obstruction of the gallbladder AEB: patient verbalizes abdominal pain of 7/10‚ grimaces‚ rubs his stomach‚ BP 158/79‚ T990F 2. Deficient knowledge R/T: lack of knowledge about the importance of incentive spirometer AEB: patient says that he does not know how to use and needs to know more about its importance. 3. Risk for deficient fluid volume R/T: restricted intake 4. Risk for imbalanced nutrition less than body requirement R/T: impaired
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A Night At The Movies: NAME: Date: 7/3/12 Points: ________/7.5 MOVIE: 28 Days 1. Briefly describe the plot of the movie: Gwen (Sandra Bullock) plays a party girl journalist from New York. Her sister is an uptight controlling bride to be. They were raised by an alcoholic single mother. At her sister’s wedding she arrived late and added another great disappointment to her sister as she fell into the cake and stole the limo to find a cake store. Gwen then crashed into a house and was
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to succeed in reaching her physical activity goals if her pain is under good control. Impaired physical mobility R/T recent surgery 2° right intertrochanteric hip fracture AEB pt. only being able to ambulate 40 ft with walker & assist x 1. Acute pain R/T recent surgery 2° to intertrochanteric right hip fracture AEB pt. rating pain as a 10/10. Ensure pt. changes position at least Q 2hr to prevent muscle atrophy & pressure sores from immobility & extended periods of friction as
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