Discussion: Drug Allergies or food allergies

Discussion: Drug Allergies or food allergies
Discussion: Drug Allergies or food allergies
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions
Findings
Current Status
1. Allergies: Food, medication, environmental
No Known Drug Allergies or food allergies; is allergic to cats—gets a stuffy nose when in close proximity.
2. Present health concerns
Vocalizes concern about hypercholesterolemia. Denies other health concerns.
Past History
3. Recent weight gains or losses?
NA
4. Previous high fevers, cause, and treatment?
Denies any recent fevers.
5. History of abnormal pulse?
none
6. History of abnormal respiratory rate or character?
Denies history of respiratory illness.
7. Usual blood pressure, who checked it last, and when?
Usual blood pressure is described by patient as normal. Checked last month at doctor’s office, reading: 100/76.
8. History of pain and treatment?
Complains of arthritis in hands.
Family History
9. Hypertension? Paternal grandfather has history of hypertension.
10. M metabolic/growth problems?
Denies family history of metabolic or growth problems.
Pain (Everyone has had pain at some time or other-if your patient is healthy and currently pain-free, you may need to use a past instance of pain.)
11. P Pain (using COLDSPA) Character: how does it feel—what sort of pain is it?
Aching sensation
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Commented [D1]: Note that examples may not be exactly like your assignment-this form is used in several classes and differs from class to class.
Commented [D2]: -1 pt. NA not appropriate for this class. Could have used “Denies”
Commented [D3]: -1 pt. “Denies” would have been OK— “none” not appropriate for this class.
Commented [D4]: This is OK because it is using the patient’s own words—no point off for this. It goes on to describe what the patient considers “normal”.
Commented [D5]: The form asks for history, which this assessment partner has—we need how long and what treatment here. -1 pt.
12. Onset:
About 10 years ago
13. Location:
Base of both thumbs and in her fingers.
14. Duration:
Mild constant underlying pain
15. Severity (scale of 1 – 10):
1 – 2Discussion: Drug Allergies or food allergies
16. Pattern—what makes it better or worse:
NSAID’s help temporarily, specifically Advil. She takes a dose 2 – 3 times per week as directed on the bottle. (She reports taking either 3 or 4 200 mg. tablets in a dose, depending on how uncomfortable she is.)
17. Associated factors— does it cause you to have other symptoms too?
Weather affect it, cold weather make it worse.
18. How does pain impact the other areas of life?
2.What are your concerns about the pain’s effect on
a. general activity? Denies effect
b. mood/emotions? Makes pt feel old
c. concentration? Denies effects
d. physical ability? She doesn’t exercise on days when she it is worse.
e. work? Denies effects
f. relations with other people? Initially denies effects, though admits that she is more irritable and impatient with others.
g. sleep? Denies effects
h. appetite? Denies effects
Commented [D6]: Could have been more specific— “constant” does describe duration to some extent…OK, no points deducted.
Commented [D7]: In the box, the student makes grammatical errors=-2pts.
i. enjoyment of life? States that it does decrease her quality of life, though not significantly.
19. Exercise, how much, what sort?: How many times per week does assessment partner get 30 minutes of moderate exercise?
Usually twice a week she goes for a 30-minute walk in her neighborhood.
Nutritional assessment: Subjective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions
Findings
Current Status
1. Type of diet (for instance, low carb, vegetarian, diabetic)
Vegetarian
2. Appetite changes Denies recent appetite changes
3. Weight changes in last 6 months?
Denies weight changes in the last 6 months
4. Problems with indigestion, heartburn, bloating, gas?
Complains of rare instances of heartburn.
5. Constipation or diarrhea?
Denies recent constipation or diarrhea. Discussion: Drug Allergies or food allergies
6. Dental problems? Received partial crown 6 months ago. Denies other dental problems.
7. Conditions/diseases affecting intake or absorption, i.e., irritable bowel disease, gluten sensitivities, etc.,?
Denies any GI sign or symptoms.
8. Frequency of dieting?
Denies recent dieting.
Family History
9. Chronic diseases? Denies family history of chronic diseases.
10. Weight issues? Denies family history of weight issues.
Lifestyle and Health Practices
19. Average daily food intake—how many meals and snacks?
2 meals per day and 1 – 2 snacks per day.
20. Approximately how many 8-oz. glasses of fluid per day are consumed?
9 – 13 8-oz. glasses of liquid are consumed daily.
21. Type of beverages consumed?
8 – 10 glasses of water, 1 – 2 cups of coffee, occasionally 1 cup of tea is consumes daily.
22. Dine alone or with others?
half the time alone, half the time with family members
23. Frequency of eating out?
1 – 2 times per week
24. Do long work hours affect diet?
Pt puts off eating if busy
25. Sufficient income for food?
yes
26. 24-hour dietary recall (The assessment partner will only need to recall the items eaten and general amount—we cannot require more specificity here since most people will not remember it any greater detail.)
Breakfast: 2 cups coffee with cream Fruit smoothie–2 cups Scrambled eggs, 2 Lunch–skipped and had a Kind nut bar. Supper: Lasagna–medium serving large salad with Italian dressing a handful of walnuts chocolate-about a 2 inch by 2 inch portion. Snack (a couple of hours after supper): more chocolate–the rest of the large bar, probably twice as much of it as was eaten at supper.
27. How many alcoholic drinks per week are
Usually has 1 – 2 drinks (wine or beer) about 3 times per week.
consumed?
Objective data: General status and vital signs
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, used with permission. Discussion: Drug Allergies or food allergies
Questions
Findings
Current Status
1. Observe physical development (i.e., appears to be chronologic age) and sexual development (i.e., appropriate for gender and age).
Physical development—appears to be her stated age of 53. Sexual development appears appropriate for age and gender.
2. Observe skin (i.e., general overall color, color variation, and condition).
Overall skin condition is healthy and the color is appropriate for ethnicity. Light brown macules present to backs of hands. Skin turgor elastic—skin a little loose on back of hands, but appropriate for age and appearance. Temperature, and dryness appear appropriate.
3. Observe dress (occasion and weather appropriate).
Dress is appropriate for occasion and weather.
4. Observe hygiene (cleanliness, odor, grooming).
Appears clean and well groomed, no odor detected.
5. Observe posture (i.e., erect and comfortable) and gait (i.e.,rhythmic and coordinated).
Posture erect and gait coordinated
6. Observe general body build (muscle mass and fat distribution).
General body build appears appropriate for age and gender
7. Observe consciousness level (alertness, orientation, appropriateness).
Awake, alert and oriented to person, place, and time
Commented [D8]: And what color is that—you must state—is it tan, pink, brown? The jury may need to know what color it was on this date—1pt.
Commented [D9]: Great use of terminology here! We haven’t even covered skin lesions specifically—we will in the next module—Great job!
Commented [D10]: Is that large frame, small frame? -1
8. Observe comfort level-does patient exhibit visible signs of pain?
No visible signs of pain
9. Observe behavior (body movements, affect, cooperativeness, purposefulness, and appropriateness).
Behavior purposeful and appropriate
10. Observe facial expression (culture- appropriate eye contact and facial expression).
Facial expressions and manner appropriate
11. Observe speech (pattern and style).
Speech pattern regular and even
Vital Signs
1. Heart rate (pulse– rhythm, amplitude) 73 regular, +2 left radial site
2. Temperature 98.3
3. Respirations (rate, rhythm, and depth).
16 even and unlabored
4. Blood pressure 110/62
Objective data: Nutrition assessment
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.
Questions
Findings
Current Status
1. Measure height. 5’6”
2. Measure weight (1 kg = 2.205 lb). 139 lbs
3. Determine BODY MASS INDEX (BMI = weight in kilograms/height in meters squared or use the NIH website:
22.4 Within normal range
Commented [D11]: Beats per minute or bpm -1. This is an assessment class, so get in the habit of acknowledging the units of measure.
Commented [D12]: -1 degrees F.
Commented [D13]: Breaths/minute -1
Commented [D14]: mmHg. -1
Commented [D15]: It is OK to use the word “normal” here because many of the BMI charts use that term for the healthy category.
http//nhlbisupport.com/bmi/bmicalc.htm). Compare results to BMI in Table 13-3, on in the textbook.
4. Measure waist circumference and compare findings to Table 13-5 in the textbook.
33 inches No increased risk for Type 2 Diabetes, hypertension, or cardiovascular disease
SBAR
Read the instructions and rubric on the assignment form before completing this. As you
have assessed your patient, which finding from the “General Status, Pain, Nutrition and Vital
Signs” assessment would require attention from the clinician (if it is sufficiently serious to
warrant medical attention) or from you as a nurse if it regards a health promotional/lifestyle
problem? Select a problem you feel to be of importance and address it using the SBAR form. If
you have a healthy assessment partner, it may be as simple as addressing that he/she gets
insufficient exercise or doesn’t eat a balanced diet—perhaps not as many fruits or veggies as
recommended. Most people don’t drink enough water—you can often use that if nothing more
serious is apparent. If your assessment partner has chronic health problems or pain, address
one of those problems below. Discussion: Drug Allergies or food allergies
SBAR
Situation Client reports constant pain in her hands—scores the pain as 1 – 2 out of 10.
Background She is a 50-year old in good health and reports no other chronic conditions. She uses Advil with effective short-term relief.
Assessment
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