Validation #3 Graded Documentation Sheets

To be completed following Validation #3 and submitted for grading immediately following the SP interaction. Please document in black ink only.
If you make a mistake in document, please draw one line through the mistake, initial, and date.

Biographical NT is a 77 year old female, DOB 1/3/1942. Patient seems reliable.

Data
Reason for Visit Cc: sores on left leg
Allergies NKDA. Denies environmental or food allergies.
Current Denies taking any prescription or OTC drugs. Denies using herbal supplements.
Medications
Past Medical Denies previous HTN, cardiovascular disease, diabetes, stroke, or cancer. Denies recent hospitalizations or childhood infections.
History
Mental Health Denies history of depression, anxiety, or psychosis. Denies previous suicide ideations. Denies history of other mental illnesses.
History

Past Surgical
History Denies history of any surgeries.
Family History Denies family history of HTN, cardiovascular disease, diabetes, stroke, or cancer. Reports parents are both dead, of “natural causes”.
Siblings are alive and well.

Social History Denies history of smoking tobacco, vaping, or drinking alcohol. Denies use of illicit substances. NT is retired and lives with spouse. She
reports meeting friends once a week for social activities.

Environmental
or Risk Factors Denies being exposed to air pollutants and chemicals, excessive sunlight, and second-hand smoke. Denies diet of fatty or sugary food.
Reports being unable to exercise regularly.
Review of Systems Interview and Physical Assessment
VITAL SIGNS P:80bpm RR: 20 T: 36.7 C BP: 100/68 arm: Left Pain: 0/10 Height: 5’1” Weight: 110 BMI: 20.8
General S: NT reports sores of left leg that are leaking and oozing. She states that she has had chronic sores on and off for three years on both
legs, some growing and shrinking over time. She reports pain of “0/10”, but states that the sores are annoying because they get her socks
and pants wet. She reports swelling in in the left leg and pink sores, although they sometimes appear yellow. She reports bandaging her
legs by herself every so often rather than daily due to healthcare costs and lack of insurance. She denies using any medications to
alleviate pain or swelling. She reports being unable to recall whether the swelling gets worse upon elevation.
 O: Appears to be her stated age. Awake, alert, and attentive. Skin is evenly toned with no obvious lesions. Facial features and limbs are
all symmetrical bilaterally and maintain range of movement, with no obvious physical deformities. Appears within normal height and
weight for her age. Posture is straight with no apparent spinal deformities. Gait is smooth and balanced without assistance. Appears to
have full range of motion in all joints. Able to maintain eye contact. Attire is clean and appropriate for the season. Exhibits signs of good
hygiene including groomed hair and no detectable body odor. Denies current suicide ideations, and depressive or anxious thoughts.
Denies plans for the future since “I’m retired and just want to stay at home”

Integumentary S: Denies hair loss. Denies cracked or dry nails. Denies recent changes in skin color.

O: Skin is dry, intact, and tan with a pinkish hue, generally even throughout. Hair is blonde, fine-textured, and evenly distributed across
the scalp and body. Skin temperature is warm and has good turgor. Nails are pink, slightly curved, with capillary refill less than one
second. Skin is generally free of rashes or lesions except for legs. Legs both have several open wounds. Sores are pink and wet with
drainage. Patient refused more in-depth measurements and culture.

HEENOT S: Denies H/A or pressure around the face. Denies recent sore throat. Denies nasal discharge or congestion.

O: Denies pain or pressure when palpating of frontal, ethmoid, and maxillary sinuses. Nose appears symmetric with no lesions or bumps.
Nares are patent with pink, moist turbinates free of lesions. No observable exudate or septum deviation. No crepitus or clicking when
maneuvering mandible. Both outer and inner lips are even-toned, moist, with no observable lesions or masses. Buccal tissue is pink with
no lesions or bumps. Gums are pink with no signs of inflammation. Teeth appear to be all present with no signs of malocclusion or
wearing down. Hard palate is light pink with no abrasions, soft palate is darker pink and smooth. Tonsils +1, pink with no bleeding or
bumps. Uvula rises midline upon speaking. Tongue is pink with no obvious abrasions, discoloration, or candida. Tongue does not deviate
to the side. Frenulum present.

Neck, including S: Denies swelling or pain in neck. Denies enlarged lymph nodes or recent infection.
lymph nodes
O: Lymph nodes not palpable. Neck retains full ROM. Carotid pulses palpable, +2 bilaterally. No bruits observed during auscultation.

Cardiovascular S: Denies SOB, chest pain, or chest congestion. Denies cool extremities, calf pain while walking, or pale fingers/toes.
& Peripheral
Vascular O: No visible jugular distention detected. Carotid artery is palpable, pulse +2 bilaterally. No bruits upon carotid auscultation. No visible
 lifts or heaves. Pericardium appears even-toned and symmetrical in width and depth with no detectable bumps, lesions, or concavities.
Apical impulse palpable at 5th intercostal space. No other pulsations detected. S1 and S2 present with regular rhythm. S3 and S4 not
present. No murmurs detected.
Both legs have several open wounds. Left leg is more swollen than right. Edema +1 non-pitting bilaterally. Leg shows no redness,
cyanosis, or pallor. Legs are warm, same temperature as other areas of the body. Palpable radial, popliteal, dorsalis pedis, and posterior
tibial pulses, all +2 and equal bilaterally. Index finger capillary refill less than one second.

Respiratory

Abdomen / GI

Musculoskeletal

Neurological

Genitourinary /
Breasts
Endocrine
Hematological
Nursing Diagnosis Statements
First Priority Nursing Diagnosis Statement:

Risk for infection AEB open wounds that are not covered at all times

Second Priority Nursing Diagnosis Statement:

Risk for ineffective peripheral tissue perfusion AEB chronic non-healing sores on leg with drainage and chronic swollen legs.

Signature: ______________________________________ Date: 9/26/19

Printed Name: Gelsey Jian