Complete health assessment head to toe Ms Paula a 63- year-old…
Question Answered step-by-step Complete health assessment head to toe Ms Paula a 63- year-old… Complete health assessment head to toeMs Paula a 63- year-old white female presenting to the emergency department with acute onsetshortness of breath. Symptoms began approximately 2 days before and had progressivelyworsened with no associated, aggravating, or relieving factors noted. She had similar symptomsapproximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD)exacerbation requiring hospitalization. She smokes two packs of cigarettes per day. She begansmoking when she was 14 years old.She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure,abdominal pain, abdominal distension, nausea, vomiting, and diarrhea.She reports difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled, requiringblankets, increased urinary frequency, incontinence, and swelling in her bilateral lowerextremities that are new-onset and worsening. Subsequently, she has not ambulated from bed forseveral days except to use the restroom due to feeling weak, fatigued, and short of breath.Past medical history is significant for coronary artery disease, myocardial infarction, COPD,hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease,tobacco usage, and obesity. Past surgical history is significant for an appendectomy, cardiaccatheterization with stent placement, hysterectomy, and nephrectomy.Her current medications include fluticasone-vilanterol 100-25 mcg inhaled daily, hydralazine 50mg by mouth, 3 times per day, hydrochlorothiazide 25 mg by mouth daily, albuterol-ipratropiuminhaled every 4 hours PRN, levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouthtwice per day, nebivolol 5 mg by mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000units by mouth daily, clopidogrel 75 mg by mouth daily, isosorbide mononitrate 60 mg by mouthdaily, and rosuvastatin 40 mg by mouth daily.Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm, respiratory rate 24, BP104/54, HT 160 cm, WT 100 kg, BMI 39.1, and O2 saturation 90% on room air.No respiratory status distress at this time, tachypnea present, (+) wheezing noted, bilateralrhonchi, decreased air movement bilaterally. The patient was barely able to finish a full sentencedue to shortness of breath.Create Documentation / Recording the Data by usingabove scenario. Health Science Science Nursing NURS 100 Share QuestionEmailCopy link Comments (0)
