Data Collection and Care Plan Cynthia Hunter
Patient (Code) New MRN:1868097 Room:406 Primary MD Joseph CODE Status: Full
Molina, M.D. Code
Patricia Newman Sex: F Age 61
Primary Diagnosis: Hypertension Vital Signs:
Past Medical History Past Surgical History Time) 07:00
Smoker 90-pack-year history. Emphysema for 12 years. Hysterectomy
Multiple hospitalizations for pneumonia in the past 2 T (route) 101.1
years. Osteoporosis diagnosed 8 years ago. Tympanic
Hypertension for 15 years.
AP 108 R 26
B/P 162/90
R 26 O2 Sat89%
on room air
Pain: (0-10) 0
Allergies: None Known Wt. 120 Admission date:
Ht. 5ft Wednesday
5in
GI/Nutrition GI: No history of dysphagia, heartburn,
Normal: indigestion, pain, or nausea and vomiting. No
history of abdominal disease, rectal bleeding, or
Bowel sounds active in all quadrants Abdomen hemorrhoids.
soft, non-distended, non-tender Receives and
tolerates nutrition and fluids Diet: Normal
Absence of nausea, vomiting, cramping, diarrhea or
How did you assist the client with their diet? None
Constipation
No complaints of nausea, vomiting, or abdomen pain
with palpation
Describe your Findings:
ting patterns:
a. Food preferences, allergies, intolerances: None
b. Number of meals/day: 2
c. Special diets: None
d. Dietary supplements: None
e. Difficulty swallowing or chewing: No
f. Fluid intake: 1 soda per day; 2-3 glasses of water per day
g. Can you eat independently: Yes
h. Do you need help preparing meals: No
i. Can you afford food and utilities for cooking: Not always
j. Appetite changes (describe): No
k. Nausea and vomiting (describe precipitating/relieving
factors): None
, Abdominal examination:
a. Inspection: Flat
b. Auscultation: Active bowel sounds
c. Palpation: Soft, nontender
Neurological Describe your findings:
• Normal Findings: Neurologic: No history of seizure disorder, stroke, fainting,
- Alert and oriented x 3 blackouts. No weakness, tremors, paralysis, or coordination
- Speech is clear problems. No numbness or tingling. Memory intact. No
- Memory intact history of mental health dysfunction.
- Follows commands and converses NEUROLOGIC:
- Absence of seizures
Awake, alert, oriented to person, place, and time. Cranial
- Behavior appropriate to situation
nerves 2-12 intact.
- When upright: Balance steady Gross
HEENT:
motor coordination intact
Pupils equal, round, reactive to light and accommodate,
- Hand grasps strong/equal
extraocular movements intact
- PERRLA,
- Foot presses and pulls strong and equal 1.Orientation: Awake, alert, and oriented
- Gag, cough, blink reflexes intact 2. Barriers to learning: None
- Patient denies numbness tingling or 3. Best method for instruction: Verbal and written
other paresthesia of extremities 4. Primary language: English
a. Read (check one): Yes
b. Write (check one): Yes
c. Understand (check one): Yes
5. Other language: None
6. Memory:
a. Short-term: Within normal limits
b. Long-term: Within normal limits
7. Decision making:
Patient makes all of her own decisions.
8. Speech and voice patterns:
Clear
9. Alternate form of communication:
None
10. Neurologic changes:
None
11. Vision (describe impairments):
None
12. Visual aids:
None
13. Hearing:
Within normal limits
14. Auditory aids:
None
15. Taste, touch, smell:
Within normal limits
, Respiratory Describe your findings:
• Normal Findings: Respiratory: Emphysema for 12 years. Several hospital
- Breath sounds clear and equal in all lobes. admissions for pneumonia over the past 2 years. Productive
- Respirations regular, non-labored, without cough of moderate amount of yellow sputum.
use of accessory muscles
LUNGS:
- Mucous membranes pink
- Chest excursion symmetrical Coarse crackles throughout lung fields, using accessory
Trachea midline muscles to breathe
- If cough present, non-persistent a. Rate: 26
- Sputum clear or absent b. Rhythm: Regular
c. Depth: Shallow
d. Quality (check one): Labored
e. Breath sounds (describe): Coarse crackles throughout
f. Dyspnea (if yes, describe precipitating factors): With
exertion
g. Cough (check one): Productive
h. Sputum (describe): Thick yellow, moderate amount
i. Splinting: No
j. Oxygen therapy: None at home, currently on 2L NC
Cardiovascular Describe your findings: Cardiovascular: No chest pain,
• Normal Findings: palpitation or cyanosis. Dyspnea on exertion after walking
- Regular rhythm, heart sounds S1 S2 present 20 feet. Sleeps on 2 pillows at night. No history of heart
- Blood pressure WNL murmurs. Hypertension for 15 years well-controlled with
- Denies chest pain medication when she takes it.
- Periorbital, sacral, pedal & generalized Cardiovascular status:
edema absent a. Apical rate/rhythm: 108, regular
- Skin warm & dry to slightly moist b. PMI: 5th intercostal space, midclavicular line
c. Heart Sounds: S1 S2
- Nail beds pink, capillary refill< 3 sec
d. Pacemaker: None
- Pulses palpable or present with doppler
e. Blood Type: Unknown
f. Dizziness/lightheadedness (describe if present): None
g. Jugular vein distention (describe if present): None
h. Pulses (3+ = bounding, 2+ = palpable, 1+ = faintly
palpable):
Carotid:
Radial: 2+
Posterior tibial: 2+
Dorsalis pedis: 2+
i. Skin temperature and color: Warm, pink
l. Edema: None
j. Capillary refill:
Fingers: 2 seconds
Toes: 2 seconds
k. Intermittent claudication (check one): No
o. Ascites (check one): No
Skin Describe your findings:
• Normal Findings: SKIN:
o Color within patient's norm Without lesions
o Temperature warm, dry to slightly moist
Skin assessment:
o Turgor normal, mucous membranes moist
o Intact without breakdown, rash, redness, a. Integrity: Intact
blanching b. Turgor: Slight tenting
Wounds: c. Rash, incisions (describe location, size, healing): None
• Normal Findings: d. Varicosities: None
o Edges approximated and clean e. Poor wound healing: Unknown
o Surrounding tissues free from signs &
symptoms of infection f. Drainage: None
o Dressing dry & intact: drainage absent g. Bruising: None
h. Lesions: None
i. Petechiae: None
j. Lymph node assessment as indicated: Enlarged superficial
cervical
Patient (Code) New MRN:1868097 Room:406 Primary MD Joseph CODE Status: Full
Molina, M.D. Code
Patricia Newman Sex: F Age 61
Primary Diagnosis: Hypertension Vital Signs:
Past Medical History Past Surgical History Time) 07:00
Smoker 90-pack-year history. Emphysema for 12 years. Hysterectomy
Multiple hospitalizations for pneumonia in the past 2 T (route) 101.1
years. Osteoporosis diagnosed 8 years ago. Tympanic
Hypertension for 15 years.
AP 108 R 26
B/P 162/90
R 26 O2 Sat89%
on room air
Pain: (0-10) 0
Allergies: None Known Wt. 120 Admission date:
Ht. 5ft Wednesday
5in
GI/Nutrition GI: No history of dysphagia, heartburn,
Normal: indigestion, pain, or nausea and vomiting. No
history of abdominal disease, rectal bleeding, or
Bowel sounds active in all quadrants Abdomen hemorrhoids.
soft, non-distended, non-tender Receives and
tolerates nutrition and fluids Diet: Normal
Absence of nausea, vomiting, cramping, diarrhea or
How did you assist the client with their diet? None
Constipation
No complaints of nausea, vomiting, or abdomen pain
with palpation
Describe your Findings:
ting patterns:
a. Food preferences, allergies, intolerances: None
b. Number of meals/day: 2
c. Special diets: None
d. Dietary supplements: None
e. Difficulty swallowing or chewing: No
f. Fluid intake: 1 soda per day; 2-3 glasses of water per day
g. Can you eat independently: Yes
h. Do you need help preparing meals: No
i. Can you afford food and utilities for cooking: Not always
j. Appetite changes (describe): No
k. Nausea and vomiting (describe precipitating/relieving
factors): None
, Abdominal examination:
a. Inspection: Flat
b. Auscultation: Active bowel sounds
c. Palpation: Soft, nontender
Neurological Describe your findings:
• Normal Findings: Neurologic: No history of seizure disorder, stroke, fainting,
- Alert and oriented x 3 blackouts. No weakness, tremors, paralysis, or coordination
- Speech is clear problems. No numbness or tingling. Memory intact. No
- Memory intact history of mental health dysfunction.
- Follows commands and converses NEUROLOGIC:
- Absence of seizures
Awake, alert, oriented to person, place, and time. Cranial
- Behavior appropriate to situation
nerves 2-12 intact.
- When upright: Balance steady Gross
HEENT:
motor coordination intact
Pupils equal, round, reactive to light and accommodate,
- Hand grasps strong/equal
extraocular movements intact
- PERRLA,
- Foot presses and pulls strong and equal 1.Orientation: Awake, alert, and oriented
- Gag, cough, blink reflexes intact 2. Barriers to learning: None
- Patient denies numbness tingling or 3. Best method for instruction: Verbal and written
other paresthesia of extremities 4. Primary language: English
a. Read (check one): Yes
b. Write (check one): Yes
c. Understand (check one): Yes
5. Other language: None
6. Memory:
a. Short-term: Within normal limits
b. Long-term: Within normal limits
7. Decision making:
Patient makes all of her own decisions.
8. Speech and voice patterns:
Clear
9. Alternate form of communication:
None
10. Neurologic changes:
None
11. Vision (describe impairments):
None
12. Visual aids:
None
13. Hearing:
Within normal limits
14. Auditory aids:
None
15. Taste, touch, smell:
Within normal limits
, Respiratory Describe your findings:
• Normal Findings: Respiratory: Emphysema for 12 years. Several hospital
- Breath sounds clear and equal in all lobes. admissions for pneumonia over the past 2 years. Productive
- Respirations regular, non-labored, without cough of moderate amount of yellow sputum.
use of accessory muscles
LUNGS:
- Mucous membranes pink
- Chest excursion symmetrical Coarse crackles throughout lung fields, using accessory
Trachea midline muscles to breathe
- If cough present, non-persistent a. Rate: 26
- Sputum clear or absent b. Rhythm: Regular
c. Depth: Shallow
d. Quality (check one): Labored
e. Breath sounds (describe): Coarse crackles throughout
f. Dyspnea (if yes, describe precipitating factors): With
exertion
g. Cough (check one): Productive
h. Sputum (describe): Thick yellow, moderate amount
i. Splinting: No
j. Oxygen therapy: None at home, currently on 2L NC
Cardiovascular Describe your findings: Cardiovascular: No chest pain,
• Normal Findings: palpitation or cyanosis. Dyspnea on exertion after walking
- Regular rhythm, heart sounds S1 S2 present 20 feet. Sleeps on 2 pillows at night. No history of heart
- Blood pressure WNL murmurs. Hypertension for 15 years well-controlled with
- Denies chest pain medication when she takes it.
- Periorbital, sacral, pedal & generalized Cardiovascular status:
edema absent a. Apical rate/rhythm: 108, regular
- Skin warm & dry to slightly moist b. PMI: 5th intercostal space, midclavicular line
c. Heart Sounds: S1 S2
- Nail beds pink, capillary refill< 3 sec
d. Pacemaker: None
- Pulses palpable or present with doppler
e. Blood Type: Unknown
f. Dizziness/lightheadedness (describe if present): None
g. Jugular vein distention (describe if present): None
h. Pulses (3+ = bounding, 2+ = palpable, 1+ = faintly
palpable):
Carotid:
Radial: 2+
Posterior tibial: 2+
Dorsalis pedis: 2+
i. Skin temperature and color: Warm, pink
l. Edema: None
j. Capillary refill:
Fingers: 2 seconds
Toes: 2 seconds
k. Intermittent claudication (check one): No
o. Ascites (check one): No
Skin Describe your findings:
• Normal Findings: SKIN:
o Color within patient's norm Without lesions
o Temperature warm, dry to slightly moist
Skin assessment:
o Turgor normal, mucous membranes moist
o Intact without breakdown, rash, redness, a. Integrity: Intact
blanching b. Turgor: Slight tenting
Wounds: c. Rash, incisions (describe location, size, healing): None
• Normal Findings: d. Varicosities: None
o Edges approximated and clean e. Poor wound healing: Unknown
o Surrounding tissues free from signs &
symptoms of infection f. Drainage: None
o Dressing dry & intact: drainage absent g. Bruising: None
h. Lesions: None
i. Petechiae: None
j. Lymph node assessment as indicated: Enlarged superficial
cervical
