Health Assessment

Case Study “Nellie”
I. Health History
Reason for visit: “She can’t talk properly, and the right side of her face is drooping.”
Client Profile: Nellie is an 84- year-old-woman, and she and her husband Ted live together in a 2-bedroom ranch home. Ted states that when Nellie awoke this morning she stayed in bed, complaining of a mild headache over the left temple and was feeling slightly weak.
Ted stated that he went to kitchen to make coffee but decided he should go back and check on Nellie. When he got back to their bedroom a few minutes later, she was having trouble saying words, and had developed a right-sided facial droop. As he helped Nellie to her chair, he noticed her right hand and leg were both weak and called 911. By the time the EMT’s arrived with the ambulance it was 0830 and Nellie was awake but was not any better.
Nellie and Ted have two daughters that live close by and 6 grandchildren. Nellie and Ted love to garden and have a large vegetable garden in the summer. Nellie used to love to cook but doesn’t cook as often anymore, she does not smoke, or drink alcohol and she and Ted walk together every day. Nellie is allergic to sulfa drugs and shellfish.
Nellie’s parents have both passed but her mother also had high blood pressure and took medication for her blood pressure. Nellie’s past medical history includes Atrial fibrillation, hypertension, and hyperlipidemia and is post- menopausal -last menses was 30 years ago. Ted also has hyperlipidemia, so they watch their cholesterol carefully. Nellie is currently taking flecainide (Tambocor) 100mg PO, BID; amlodipine (Norvasc) 5mg PO, daily; aspirin 81 mg PO, daily; simvastatin (Zocor) 20mg, PO, daily; and lisinopril (Zestril) 20mg PO, daily.

II. Physical Assessment
On arrival to the Emergency Department Nellie became more confused but was able to state her name but not the date or where she was. She also was unable to stand on her own. Vital Signs on arrival to the emergency department were T: 37.4, P: 100, RR: 28, BP: 178/96, Oxygen Sat. 92 on room air. Nellie is 5’3” and 120lbs and appears well nourished. She is unable to verbally state a pain level, but no non-verbal indications of pain noted.
Nellie appears her stated age but acts anxious and is looking around for Ted. Nellie’s skin is pale, and cool to the touch. Nellie has a non-blanchable redden area on her left hip about the size of a quarter. Nellie’s speech is slurred, and she is having difficulty finding her words. Her head is round and proportional for her body size with a right sided- facial droop with drooling. Nellie’s pupils are equal, round, and reactive to light and are brisk. Nellie states that “things look a little blurry”. Her sclera is white, and conjunctiva is pink and moist. Lungs sounds are clear bilaterally in all lobes with no adventitious sounds heard. S1 and S2 sounds with no murmur heard. Radial pulses are 2+ and regular. Dorsiflexion, and plantar flexion are all weak on the right side. Her abdomen is soft and non-tender with bowel sounds in all 4 quadrants. Nellie has stress incontinence and is voiding clear yellow urine.
 

Please answer the following Case Study questions:

1. Highlight relevant subjective information in yellow and objective information in green.
2. Are you missing any information? What further subjective questions would you want to ask (about Nellie)? (Name at least 4 questions with rationales)
3. Nellie has been admitted to your unit and is your patient. List 3 priority neurologic assessments and 1 routine neurological assessment that you anticipate performing as you care for Nellie (explain your rationales for your choices.)
4. Write a SOAP note using Subjective and Objective information to summarize the key health history and physical assessment findings.
5. Finish writing the SOAP note with A and P.
   a. “A” stands for assessment. Review the subjective/objective data to help determine Nellie’s nursing diagnosis. List the nursing diagnosis and supportive data in the “A” section of the SOAP note.

b. “P” stands for plan of action. The Plan section outlines the course of treatment, health promotion, and can also include patient education. What patient education will you share with Ted and Nellie regarding her current diagnosis. (Minimum of 2 teaching points)

Use the format below:
S Health History

Biographical data: 

Reason for seeking care:    
Present health or History of present Illness:   
Past Medical History: 

Allergies:

Last menstrual period:

Medications: 

Family History: 

Social history: 

Nutritional Habits:  

O Physical Exam
Vital Signs:
General Survey:

Skin:

HEENT:

Thorax and Lungs:

Cardiovascular:

GI/ Abdomen:

Neurological:

Musculoskeletal:

GU: 

A Assessment

P Health Promotion