CRITICAL THINKING QUESTIONS:
Answer the following questions. No more than 250 words/question is necessary to answer these. Your responses must be typed and in APA format. (10 points). It must be submitted by the beginning of class on Thursday June 9, 2010.
- What problems can you identify for Mrs. Malone after completing her heatlh history?
- Based on the information provided in Mrs. Malone’s health history, what will you focus in on in her physical assessment? Based on the information provided in the physical assessment, is there anything missing or might need further attention?
- What are Mrs. Malone’s strengths? What are the areas of concern?
- Based on what you know, what would you consider 2 nursing needs for this patient? What plan?
Marcia Malone is a 40 year old woman who comes to you for a health screening. She is seeking information about routine health screenings recommended for her age group. She is concerned about her risk for osteoporosis and has several questions about menopause.
As you speak with Mrs. Malone you note that she is dressed appropriately and that her hygiene is good. She is oriented to person, place and time; has appropriate affect, has well-developed language; and presents her ideas and concerned in a relaxed, coherent and logical manner. She appears well nourished and healthy. Her biographical data, although unremarkable, give a few important clues to her current health status.
–40 year old woman, Northern European extraction, Protestant, Married with 3 children ages 12, 15 and 18. She has a full time, sedentary job as an accountant. She seem reliable and a good historian.
–she has no current health problems. She is concerned about physiological changes of approaching menopause and health care recommended for her age. She occasionally takes acetaminophen for tension headaches. No other medications.
–she has had chickenpox, measles, mumps and rubella as a child and also frequent bouts of strep throat as a child.
–she has an appendectomy at 15. Was hospitalized for birth of her 3 children; had a tubal ligation at age 35 for fertility control; has never had a serious injury requiring hospitalization
–no history of medical problems; no drug, environmental or food allergies; she has taken penicillin without a reaction
–had all childhood immunizations and has not travelled to any foreign countries. She has not served in the armed forces
–Husband, son and 2 daughters are alive a well
–Mother age 76 is alive; had breast cancer at age 54; osteoporosis and fractured hip at age 63
–Father age 78 has a history of hypertension, and a myocardial infarction at age 68
–Younger brother died in a car accident at age 35
–2 sisters 42 and 50 are alive and well
–Maternal grandmother died of breast cancer at 78
–Maternal grandfather of MI at age 81
–Maternal aunt, 78, has hx of breast cancer
–Maternal uncle, age 80, hx to HTN
–Parental grandmother died of stroke at age 82
–Paternal grandfather died of MI at age 86
–Paternal aunt age 65 is alive and well ; aunt 69 is breast cancer
–Paternal unlcle, 71, hx of HTN
REVIEW OF SYSTEMS:
General Health Status: Patient feels that her overall health is good. No fever, chills, fatigue, depression, or anxiety; she has occasional colds and has gained 10lb in the last year without change in diet.
Integumentary: No rashes, lesions, mole changes, or bruising. Skin is dry and hair is graying slightly.
HEENT: No headaches; no frequent sore throats, hoarseness; or problems with vision, hearing or sinuses Last eye exam 2 years ago, does not recall last hearing exam. No problems with mouth or teeth, 28 permanent, wisdom teeth removed. Last dental exam 6 months ago.
Respiratory: No shortness of breath, wheezing, or cough
Cardiovascular: No history of HTN, heart problems or murmurs, deep vein thrombosis or phlebitis, chest pain, palpitations, edema, orthopnea, or claudication
Breasts: Performs breast self-examination (BSE) occasionally, when she remembers; never had a mammogram. No breast pain, tenderness, masses, nipple discharge or changes in the nipples. Has breast 7 days before menstrual cycle. Breast fed all children
Gastrointestinal: No nausea/vomiting, abdominal pain, dysphagia, heartburn, jaundice, hemorrhoids or blood in stool. Has daily, formed bowel movements, brown in color
Reproductive: Last menstrual period 21 days ago. Menarche began at 14, Gravida, para 3. Menses are irregular, ranging from 23 to 45 days (cycles used to be 28-30 days). Menses last 5 days with moderate to heavy flow. Contraception method is tubal ligation. Satisfied with sex life except for increasing vaginal dryness
Musculoskeletal: No joint pains, swelling of muscles weakness
Neurological: No dizziness, vertigo, syncope, head injuries, seizures, numbness, or tingling of extremities. Reports forgetfulness and difficulty remembering, Has never been treated for mental disorders, depression or anxiety but did visit a counselor about a family problem 3 years ago.
Endocrine: No diabetes, thyroid disease, polyuria, polydipsia, or cold intolerance. Weight gain is 10 lbs over the last year
Immunologic/Hematologic: No current infections, allergies, cancer, anemia, or blood transfusions. Blood type is A+.
–Does not usually seek routine health care or screenings. Feels that she is healthy and does not need health care unless she is sick. Does not know her cholesterol, has never had a mammogram, has not had a Pap smear or physical exam in 3 years
–Typical day consists of arising at 6:00 am, getting her children off to school and then going to work. She works from 8:00 am to 5:00pm. After work she makes dinner for her family and reads or watches television. She does to bed at 11:00pm each night
–Reports that she eats a balanced diet with foods from each of the major food groups each day, including vegetables and 2 fruit servings. Admits to eating sweets each day. Evaluation of daily calcium intakes and reveals that she ingests 500 mg/day. She has an unexplained 10-lb weight gain in the last year
–24 hour recall shows the following: Breakfast was two fried eggs, two slices of bacon, two slices of white toast with butter, one 4-oz glass of orange juice and a cinnamon bun with butter. Lunch was a chicken salad sandwich on white toast, potato chips, two chocolate chip cookies, an 8-oz cola, and a chocolate candy bar. Snake was one apple. Dinner was steak, baked potato with butter, string beans, tossed salad with Russian dressing, apple pie with ice cream and 8-ox of 2 percent low fat milk.
–Admits that her only exercise is walking from the car to her office twice a day and walking up and down two flights of stairs several times a day. She walked on a daily basis in the past but stopped this year because of lack of time and inability to fit into her schedule. For recreation, she reads, does housework, and gardens on weekends.
–States that she usually sleeps well 7-8 hours a night. Has occasional night sweats than awaken her
–Has never smoked and is not exposed to smoke at home. Has smoke and carbon dioxide detectors at home. Drinks a glass of wine with dinner two to three times a week. Denies use of illicit drugs.
–Identifies no occupational risks. Is not exposed to smoke at work. Drives 40 miles round trip to work each day and wears seatbelt when driving.
–Attends church weekly with family. No religious or cultural influences that affect healthpractices.
–States that her marriage is supportive and comfortable. Describes good relationships with children, siblings and parents.
–Uses prayer, friendships, and family support to deal with stress.
You have done a head to toe assessment of all systems using all of the assessment skills that have been discussed/practiced in class. These are the findings:
General Health Survey:
–appears younger than stated age; well-developed, well nourished, neatly dressed and well groomed oriented to person, place and time, appropriate affect, speech clear and responds appropritatetly, no acute distress at this time, moves all extremities well, gait balanced and coordinated. Height 5’5”; Weight 145 lbs VS: Temp 98.8 F, pulse 74, RR 18, BP, 128/80 Pain 0 (0-10 scale)
–skin even in color, warm , dry, positive turgor no suspicious lesions; White scar from appenedectomy on RLQ; hair clean, coarse, slightly graying, evenly distributed. Nails pink, brisk capillary refill, no clubbing
–normocephalic, erect midline; facial feature symmetrical; thyroid not palpable, no palpable lymph nodes
–Snellen: R 20/20; L 20/20 Both 20/20; Color vision intact; difficulty noted with near vision; visual fields normal by confrontation; EOM’s intact, no nystagmus; corneal light reflex symmetrical bilaterally; no drifting; eyes clear and bright; positive blink reflex, no lid lag, ectropion/entropion, or lesions noted on lids: cornea, iris intact, anterior chamber clear; sclera white, comjuntiva clear and glassy; lacrimal glands and ducts non-tender; pupils 3mm, PERRLA direct and consensual; positive constriction and convergence: Red reflex present bilaterally, discs flap with sharp margins, vessels present without crossing defects, retina even in color, without hemorrhages or exudates, macula even in color
–Skin of exte4rnal ear intact without masses, lesions or discharge; angle of attachment <10 degrees; tragus, mastoid, helix non-tender; positive whisper test; Weber tes:no lateralization; Rinne Test: ac>bc bilaterally; External ear canals clear without redness, swelling, lesions or discharge. Tympanic membranes intact, pearly gray with light reflex and landmarks visible; frontal and maxillary sinuses non tender; nares present; patient recognizes familiar odors; Nasal mucosa pink, septum intact and no deviation
–Lips, oral mucosa, gingivae pink, and without lesions; teeth all present and clean; dental work present, no obvious caries; pharynx pink, tonsils +1, palate intact; symmetrical rise of uvula, positive gag and swallow reflex
–Respirations 18/min unlabored, trachea midline; AP < transverse diameter; chest expansion symmetrical, no tenderness, scars, masses, lesions; equal excursion, no lag, equal tactile fremitus; resonant percussion sound over lung fields, diaphragmatic excursion 2 inches; lungs clear; no adventitious breath sounds
–PMI 1 cm at 5th intercostals space at midclavicular line; heart rate 85 BPM and regular: S1, S2 no S3 or S4; murmors, gallops or thrills present; Pulses +2, no bruits or thrills, no varicose veins; JVP 2 cm at 45 degree angle
–Symmetrical, no masses, nipple retraction, nipple discharge, lymphadenopathy; abdomen flat, no masses or pulsations; bowel sounds present, no vascular sounds heard; tympany in all four quadrants; liver 8 cm at right midclavicular line; abdomen soft, no hepatomegaly, splenomegaly, masses or tenderness; negative abdmominal reflexes, kidneys nonpalpable; no palpable lymph nodes in inguinal area; aorta 2 cm
–External genitalia without lesions or abnormalities; vaginal mucosa pale pink, dry with few rugae; cervix pale pink, no lesions or discharge; no cervical motion tenderness; uterus midline; normal size; Adenexa without masses or tenderness; perianal area intact, without hemorrhoids; rectal wall smooth without masses and tenderness, stool brown; occult brown negative
–Normal curves of spine; no scoliosis, kyphosis or lordosis; Joints and muscles symmetrical, nontender, no deformities; Right side dominant, arm and leg lengths and circumferences equal; equal hand grasp; muscles well developed. +5 muscle strength; Full ROM in upper and lower extremities; no crepitus
–Awake, alert, oriented to time place and person; cooperative responds appropriately; CN’s 1-XII intact; gait steady and coordinator; no pronator drift, negative Romberg; able to heel-and-toe walks and do deep knee bends without difficulty; point to point localization intact; superficial and deep sensations intact; +2 DTR, + plantar flexion, negative abdominal reflexes.