Nursing nur 509 - Study guides, Class notes & Summaries

CC: Patient states intermittent chest pain that is tight and uncomfortable. HPI: Onset: Earlier in the month Location: Middle of chest, does not radiate. Duration: Pain lasts “several” minutes. Pain passes with rest. Has experienced CP 3x this month. Last episode of CP last Friday per patient. Characteristics: Denies sweating, nausea, vomiting, SOB or palpitations with pain. Has never experienced this pain before. Describes pain as “tight” and “uncomfortable”. States pain a ...

Tina Jones Seen 1 month ago to establish care. S. CC “My throat has been sore…and itchy. And my nose won’t stop running. These symptoms are driving me nuts.” HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example: Onset: “2-7 days” Location: Throat, 4/10 Duration: Steady weight loss, 3-5 pounds per week Characteristics: “sore” throat…”jus...

CC Pain in lower back. “Tweaked” it while lifting a box. HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example: Onset: 3 days ago Location: Bilateral lower back. Does not radiate. Duration: 3 days Characteristics: Described as an ache, constant, does not radiate. Pain at its worst when she first injured her back stats 6-7/10. Current pain 5/10. Aggravatin...

S - subjective CC: Ms. Jones reports getting into car accident 1 week ago. Has had headaches ever since the accident. Pt did not hit head during the accident. Friend’s car had little dent in back bumper, car that hit Ms. Jones and her friend had a slightly bigger dent in the front. Stated as “not serious” per patient. HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the ...

NUR 509 Neurological Completed Shadow Health Documentation GRADED A+ /NUR 509 Neurological Completed Shadow Health Documentation GRADED A+

nformation the patient or patient representative told you. Initials: T. J. Age: 28 Gender: Female Height: 170cm Weight: 86kg BMI: 30.8 BP: 140/81 BG: 224 RR: 20 HR: 89 Temp: 98.5 SPO2: 97% Pain (1-10): Denies LMP: 1/14/20- irregular; every 2 moths; or 6 times a year Allergies: YES Medication: Penicillin- rash/hives Food: Denies Environment: Cats and dust- itchy watery eyes, running nose, exacerbates asthma wit sneezing and wheezing. History of Present Illness (HPI) “It feels like it’s been h...

Annotated-NR 20509 20week 202-1 SOAP NOTEOnset Intermittent chest tightness the last couple of days after being near cats Location Chest tightness all over Duration Intermittently the past two days Characteristics Chest tightness no pain. Aggravating Factors Worse at night and lying down, cats, and dust. Relieving Factors Albuterol inhaler Treatment Proventil 90mcg inhaler 3 puffs every 4 hours. Current Medications: Include dosage, frequency, length of time used and reason for use; also include ...

NUR 33630 Vital Signs Nursing Test Banks Chapter 30: Vital Signs Chapter 30: Vital Signs MULTIPLE CHOICE 1. A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure ANS: C Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temperature control. The hypothalamus does not contr...

NUR 509 FOCUSED NOTE: CHEST PAIN BRIAN FOSTER (GRADED A):Chamberlain College of Nursing |100% CORRECT