WOR 101 ~ HEALTH ASSESSMENT FOR SECOND CLIENT Co ——————— Sede wo Sollee oles or pigmentation changes: yes GG) Rash: yes LAD Scars: ¥@'/nq Excess dry skin: yes tp Bruising: yes GD) Desde ay devin stove MelPple opty toevinds cn blah Vertrewihis and Seerumr, Saronded by sac tssve, Braden sin axesmentvore: | tes of potential skin Drader: Bo Prrwinsnsts Frmntoict Jour Srcew late) ankles nim, wn, do oie Blend label nee, Sage TE lees, chren'e DresinpExedrg woth tuned Vee pins Sine Temperature: WOM cer prwk Tao: Y8 teding sev wider: Movs re ported Fa oe ener Snel appr, Mole pock Hygena e6> 0, debe Large. amancty of ptt breskfust belay chin jon shied ~glucts, ia Meus arent Steabes. “Nurses da Haak’ Daly tion: Aaptacs adeguete Headache: yes 4a Pain or sifess aun: yes / 9) Diziness or fainting: yes 1 Enlarged lymph nodes: ys 18) Duscribe any deviations identified above: © eee vith vsion @/00 yes, describe: Dstomce vision 1s tntack, bit aust v0 reading gligs Mon small pricte, Oeesoribar oud gphis tenes Heat vem Learb ace Som equal bilderalig, Corn, recchioe Wlight-oeacdenserta) ad atconsdesi Scare Wea lia contac: agate of lest wien or glee heck | Lac Use of Acesory muses: yes /GD If ys, descier © Cough: yes 16) ys, nonproductive / productive CI describe sputum (mae & ee Mf het synmety Lgeel let AP Pavers Roba | Sookng history: BR pack guers, Quit 4 yout age. ayn: oom ai Speen OM wing appemental Oye? fow rate & ype of device Yin vin nace/cnanele bind bind Pate ovine, 7S om ic LGB y=? fw rate & typeof device ML, vou eral Cenaede Avi: ear nd eq ata in al lng oes ye. i deste: eg sand, eehereckles i. all Feld, uel afl hile Povo: ear an eu tral in al og hes - yen, derive coral assess fasherioe long Flde If ot dew Latera:cear and equal biter inal ung oes = yes 9 Wt no, deste elt crackles ta all Fads. ae it ot ot cet Hay Wickens ale ott Tat Uickersn ak iden 4 yea SS ———— “hes pain or palpitations: yes [49> M ys, descbee © Dye on exertion: Lan yes debe ig in aig et ran tag: Pel bene) ap xecfn er apes Ii Pave (xt peng ZG, regular rook ~ Clg bone fail pe: ft” Ceeder ehetteghng, Zt ‘Heart sounds: > 5 at tel and rapid ts «4 (no no, descibe:_AU Kea t# hones are titant aft eaborrphic baby belies > Sat aortic and pulmonic sites: gps fon no, describe: fsa somds— yen lon yes, de AG a Mey a Hibs moked? Bleeding tendency or excessive bising: es / 62 Color changes to feet or ankles: €@ /no Edema: B>/ no Lymph node sweling: yes / Dysuria: yes ip ~ Polyuria: yes > Heitagy ye.lG Wye oan, decide: Fonhonalic, eortret dit peraplesia, Feels [ile sinstine atedlas nad inne Typical urinary einai patter, Le Wine Characeite known Describe any changes Ute wm Cather pe 8 ag np lke Mateaece of repr ent ie eis wd ty, Nutr tome ercess CoSOeeS ate oft oho: fate eurologcal: History of sires: yes (9 Stroke: yes iO Fain: yes tp Blackouts: yes My If ys, describe: 2 Problems with nervousness: yes GB Mood changes: yes do Depron: YBo/n0 Ihe to abo, decide: _Tegerts prot it is lead by be wpbut when coufne) te ber bed. (cocaiTion) LOE: eo 1 pce | iain: *“S_—Memory (wmv dur, dain ys CB) ys, describe: mon need, facial expresion, and apropiatenes): Ma spears he stuhin, tepression: ntdral and subdoed eb sines ‘(LaNGUAGE] Speech/commonicaton: Gala | aphasac MW aphasia, describe: Conwtad wurves L~XM are bhocl by tamination (ne Muscle: Pain owen: €Ln0 Cramps: yes 6) Wenkess gGB/n0 Problems with coordinated activites: {@)./no Fear of fling @/n0 Hand grasps (roy & qual they: yED/ no Foot strength with plantar flecion (neg teqa!wnuais yes Af) V0 abe, ducide Blatt Pedremty gucolssic, Me sensing ox parheJoint: Pain (cousea: @EBVn0 Stiines GR /no Deformity: yes /q) Limitation of motion: YEE no It yes to above, deserde: Rains Rt Shovlder{see COLBSA pu, 1) Probes with gt or anbuaing: Vo bola bine Asie devices wed am wy ox 0, Agar Lp Numbness and tingling: 21 no M yes, describe: Wo sensehrorn Crane Weis deca, ‘ny problems with eyesight, auditory, aco, or gustatory ables: I ys, dexcrbe: <> ———_—S— MLAS wipe GB” wiehe SB4S i wet pinot sine re and weber ita wwinantny:G0/6 wight os su Dee Ad estichin Food allergies / intolerance: Nowa, Use of vitamins / minerals / supplements / herbs: “Ome Precedence lod eit eget of ppc: Gnd od Poor Nase /Yoniting ys ge ye, deste: & Thc amen ato (Beast: FOZ und: FO% ner LOA Sead (pe & hegengy Me Ahecringes aud HS. Serbo Je My Tube feeting: Formula: © Rate_ 2 Route: SF intake and output yes 1D Mo, deste: Excessive Qleid iwtekee cot reseltiy wert Pin, Woo ou 1500 may [im Adequate Fecrbte imbalance: ys > W yes deve: > [Refer to mediation ft] Medication — Substance a Problems / concems regarting medications Blor schedules: AG concerns reyourted States “nurses tht care of all phat" Use of over the coumar medians and ote subanes (herbal / bane remedies, atin, nicotine, abo, recreational dug 2” 1 st ab, deste day inal: ne rae a hei ls ov cena pty ab echaerdaasie Depo aly 0 2p Les bed haviad, Tpically gant dire shy webbing TV. arin his ad yates: Manes ee erate “about bars" Night aching: ys 106) Wye, debe Pepi ps Manas Fek/agpean reed vpn waking.) Slicer nergy to cay ot ADL: ys 16D) Ho 0 abe, deve Completely tolerant ‘wl achisits, Sebi >I cr log rolling cesses medereke Aepnee“dbras Mavs. repo ed is (hamaciogial Ua pharmaco: Bigap dfs OSA _abconcpt- Cam Response Safety Peer pt ape aks" ate bray hack “tad helps ber tary on, ay age = (eis Y's ep, ppl Uae / en pyc pal: ys Le Wh, dec Se dowel abot playsicaf funathy ener Factors intering with sep:‘Seunalty Wistay ofS: Moms ceported Date of last menstrual period (Ghapaus®> 72 yors age Date of last pap smear-Dest nit cecal! Koovedepracc se beater exam, Cuieck — ne Lnod gl ® mee of bith conti ser et appliceble at ty pc SHehes "(butt se bo do cagbhin" and Ast “avcste (ust dab“ ers ley — (ees, sal pais, teow rg ring) Maw sialon moving, oles Keeps she up cal ight of Side Fa ik assent eas > “OH clei ag tal a: PE 15 Bed bond), Mas assict alan. Conia wit planed intron: & ln W no, describe: Use of assistive devices for ambulation I yes, describe; ME. Derapleg scx Des wee ay ey msrp week Coll (alt ond cf remas tarkin reach, fils yp, Bed lou) (tgler pt olagkt. Do you fe sain your ng emiwomen? GL 00 We, debe — Say of pint care area: Liphing adequate ino ter re evinanene Yeo GA ihe aces: ne ‘Social Actrtis . Suc acie fr veie, bw lr raion: Watcles Téleitin, ag prssnry, acrurby, Does utt tisk te pecherpehe sn sets) aohihes ‘Belanonships . # of Ciena 4H of Ginn. Nave, Aen vith amily sipicant ober, ad yes Mover meeccied, Yo chaldee, Qos heather the prison he hfe. ayes oe it kw pr sso tay Vv ors Have cose in gue 0 Urug Home (per steht Hoi your faniy cing wih yor crt ath stad Wot opabicable Sans Ll Copig Sot Famitsu poas oti AV te Fal ana teat & tenet, age ice conn Woh adored dese lone 7 Wat fs pu staged pe 7 Coleve x Ged" and Ahis gies he peace Desi penonl health pracices used and wheter at not they have been be Coping methods / Stress management wcnique! Relaain eercse: Denies eee being Hust ams coping s1etbeds , Kes" tly ors yall hen eve than : Significant stressors in the lat 12 months fedng ween tice Berbovad selbgle Maye aceinivie rye Silly idee, Depress, Dect end ses mange D088 sat tolerede, external Stresses well of all, Uden tvedtod, set uithdnuss. Client's overall rating of health: Poor 1 2@ 4S 6 7 8 9 10 Excelent‘Self-Care Deficits: Highlight areas of self care deficits, cluster cues, and Ilst 2 or 3 top priority client problems / nursing Nlagnoses. ‘ - 5 Ipoinad skin Aescohy Yh phyocel iamobiliaadon, presure, aul miithee ach hw melt le, eres of chronic seeds machealing uleees , & butited ascoceness of tneatinence of - eves Urinary Hncolionces Ht pane Fonchonny defnsar mscle ab, perplgia 5 S00 oF bilateral loser enbrenity paralysis, lock of sensation belo unbiliias, and reported wuelottany orne leakage. . InePedive heath Heicdtrance eft cognate mparrmet and dintinizhed Finn or gras moder shls, a aoeb lack of expressed jichrest iA impriving Meath behnmers, lack of knotedge about bore heath practices, downsteted lack of adaphve behaviors to envirermitutes changes and impaired ! mepet ayston. ‘Nursing Agency: Identify the top 2-3 priority nursing interventions for the Identified client problems / nursing diagnoses. 1 The wurae coil l Identitag anderliyvay condition 2 fathslan, aveleed ite aed sks indyrty, A Debrmine Chants o96 ond derlopmertel Refers and/or chility be core he self a 2. Eaboake chet chon are gpacles aod lagins sats, : 4. Asses blood spply ond seuschion © shirserees am accgulen bais, AT muse cull: Renees cheats lustng fir codribshing Retort sock es n0m-Rmchowiny debnse/ anaide, sertory or motor dotiuctinn om actowic: bladder muscle +o % Deberrime degpee of discbility 08 Ated 4 Uren dyshuchin. eo 5. Calleborade tn trectnet of owtetying conditions 1 Smale wallras by eFtablihing a rguler Scheele Le Valle enptaag chelhar voidmg 27 ving © untany cotheherr Vs Deterwine HOS cosuitine emutionl, physical and! Sevtlopertutes chetus axth love! Baca gens Woke desing aed led of ebfity te meet healt sairtenance needs any 7. Help chat te develop reclistc hee Mhcace goals, STL wiese att TORT ts tn te pt te a Fiat bad very poor Hein oor practice, encmreged gt fo ress veilite aback orinmess reactinence ond A woh eteA? pronptty te decrease erstire levels inthe pelbi sri A Tenrownyed thr pediok Hy aek boeeds mating ¢ sehedok Ke Medder emptying, b+ pected wos mot receptive to ts gual, / BT thenagy encniraged The pcbiet te tke an achue role TA ranging Ker cute hearth. Ab did Wot ads iate ony hcécest in Managing or jmnprowny heron health, Instructor feedback regarding client assessment and plan of care: Satisfactory or Unsatisfactory Overs, | ettempted ty edvcte and trearege this potion t fo ply a Tanger role bie tain, heath Mertinanct, Wrtheat muy rearercble sxcess,15" PATHOPHYSIOLOGY for CLIENT #2 Desctibe the disease process, signs and symptoms, diagnostic tests, possible complications and treatment. [Be sure to reference source.] Pressure Ulcer oF Sach region Conrshageable), open Wounds om bilekeced letenl aralleales. fi of J. } fissve, of varie ure vleer is am oer OF damage 7 ine Typreat causy a ove fe pressurc ee issue, aad muscle pssurt, by Phe wes! of the indurdva! pabiest. The press gewrcted cen be afteten fran Pre cepillaray Fil pressere Corvaltey ero FamaHy), which limits bos ou te the oPRcted: area. Pahets wot formal Sensory ond col are typically tot lhely te develop snvler, a Phe would sifton. 3 needed, Phets the oa Heamobile/ linn Ped atobs le ty , we & Lnely mrpaiced are at bug cok of developing posure uke, or ere Cosnctve g lg Jeeded one bony prominence, 5vCh 5, Baty (S readened Hse, now blandeable. Typreally laetec ony z oa Eo (thad) need Jackla. elba.), Bled PhasfoHis area it Compre ited on at igh risk, 4. Staga I Portal Thacleness * hes wadlet Sbigh 4 bruising. Tpeally ‘ i 8 Stage T= Fell Thucknasg: Eprdernis Deri and Subcstaneses (ayers 2 shiv cre domege © oy : eo oc Fender 07 bak 'S neh wiped, Deel of bowed con Very Widely depending ee omademnces logtion, Passible funeling andar o fe ting 4. Stage TE’ BN Hhcknes tse eS. Bone, moss or fade ta expend, oft ttle te cthonyelehs ay be wey patel dee & epee ve, cond aseessmeit, volucl imelides Degerhe Tess * Thacaushs nea di primary rxeted Re presse 8 aaa he velvet ng woud sree, lacechonn, depth, awelin earn cens cg ira a hy ¢ SY, Eten, WBC tNarcetes WAectron «Rabin: Alera oy Tantheer , ec c Prete te > MOma/te hee askenrngel 15. devel, cot wets process Baek maid Peal WBC or CdifP Blood Cotbucs Pripsis susp: an Keahine | Peemaniah Hisrve damage meccoris, lost of Vb, sepsis, eoftomyelits , rechlfoanang/ agnud Fishle an gt 1 Varies depeading om the. Glureeter oF tie wound, Hoga T al D esvelty Lave coneinvedrue techne ts, Teta Yair pd Ne can ad dy, Shy HE ww mtn ty eae tre ve treat met, Suck as aegicat clesuee, Hom) vac, om pecking, Most pressure ukecs ore hacled by Seandery deh e A thges Myuire eedechon oh pressuce + alas tumaad blowd fas $ aro, Identify the specific assessment findings (signs and symptoms) that your client exhibits compared to those you noted jin your pathophysiology report. Sacral ver, uuplags ble. Bikite pal labeced Mallee apex word € Wong RE Parops Ralysis of biel lnve otremities, wth comprymised baton searony Neve € pathways PAL edema, Viren (tins on elves. J sites and Desesse Process? A Sept, and mollrp te covets. fe exerted on the Skin soft moter cout Fasuds os 0 shallow open oleer om oF an Ket 61 painRl. Bool ede om Bcherge Sources Erica, moedstepe cm fade e/ fo mera prem ck gee "Shope of. pekawre cle S" Atl, 2002 Cowaree2° PATHOPHYSIOLOGY for CLIENT #2 Describe the disease process, signs and symptoms, diagnostic tests, possible complications and treatment. [Be sure to reference source.] Renphanh Vesculer Diseese (Pus) bated Psa Process: Ie a distescferedfie, 1m Which Be vascular systems ofl actenres, wteegemhin cece inhi 0m Oe OTS Ce ite Beals imal Biloed Prove bet. jute and act Bein tassves 1 He penpherel pack of the body Cmts). Tre decressch blood Plow reals im ineBechve herve poRsit, which can caore cell death pasts cad once uracil tot Mabe a tesaick ty « healeang of Ba vssd walls, Ca ee Tan 0b tha vessel wad marry, FPlamie mth stag Tia vl walle are Pen caleifed, takin thm enable te ty cmtleictor regal 6 avdize ous The elethed rederal cam ake breck Leg Some the uesiel Wells creating an eee evil beeing lodged i avettar blood vessel, potudially causing ao CUA, MI, on PE, eauckeoeny Atheco is ts a build up of Retty chulecterdls Fat covee a mamonins plgee The ‘paltep com Clave Blowd) Flow to Pre aces dawns tres, Crm the buildup, ane a plage cuphine ram Fornr am ental! se & sinker manner as atenoscleasis, Se: PVD eMuprsett os ndemitlut clavdeatin, hich 'sthe tay toce mot reciting sMivet bleed flew, vtahyy Whetaueis a hgben demeud he theiinerered bol fou, hn ran ph wlkong, toning Prin exes when sf ive Wad Flees Gilet pirhse Hssves, bub gus anny aMle serine 2 Th limb tray howe constant dscoubenct aren at rest, ty bance wands or ukers Pat are slouy te heal onde mat Wal af alt, Lats may be Sellen o have eden dt venoes rDev. Sma ail vote bedy ore afeded, pallets ake tapertuce Cline pablens, exci fyshon thy 8 vinden dementio, bypeensinn Me renal artery stusr: Dinguaic Tests! Reha bled work py show ABin/eredinine, whet om incline muscle damage breakds deste, en deetia, D deme CRP, beteakinG ny rndreake flermction a fone Doppler sldaceunls, perphical dayuictit ausiosmaphes, (Tenge ar MEI ety chow areas of Plaque buldep and Compronstad Gredlchor, aid = ose! to evolucte ble! flow wfc ABI ankle-brackioS fadey' measeres BP im enkle aud arnn nod use! hg hate ty he & cline om triad well derand wes 4 fern heehias: De id pees cause 4 , Keresed utrelsfachuty tolerance iy . Pigs chon Seared aul cause Mi, ova, PE, DVT: pada ny lead Flic Plat., ret: Meh Jo preva blted elating 'W nurraurd vessels, ; 7 ees rab fatere + Seah HI, Nigh chested, Mai et. read ~ pracphece) cmusis plasty te Sng) « endarterectomy, 0 WS bopecs Identify the specific assessment findings (signs and symptoms) that your clignt exhibits compared to those you noted in your pathophysiology report. Decree) Cited cron i plat Vest. lan phe shength in bled bok DP PTT fmccersed beling bre x brlabamed ay wormds lar changes infect Ue ¥ bool blow), Lapectensins, Uhely de conal artery Shewsis Me pees agogerphy all perotvanss perphicd hebvtedas!a tht FA ad i realchy Sarees: Entadierin maedsenpe . com/a-thele | HeISSE- Overwies Waste “eyelet besdd Shty nndence, oak Reber orteane sand prignss of [Sclanave feaphereL Vesccler Mchensl eve, imahecbint Cor prevetion® Haecd) COMME, 2816