I am a third semester RN student. I have a big care plan. I cannot decide how to fill out the review of systems since my health assessment book clearly states "Subjective data, positive and negative, that the patient offers--what the patient tells you as stated by the patient." Their is NO H&P in her chart. She has skin breakdown and heberden nodules and disfigured hand, yet she denies arthritis, basically she denies everything. I know this is the section where we use the word 'NO', ex: No fever, chills, malaise. I am confused, if she has a temp and yet denies it...am I reading too much into this? I am unsure! In the physician ROS it is more like our physical assessment
of the systems which follows this ROS section. Below is what I have for physical assessment of her skin, hair and nails, I am lost what goes under ROS. Any help with this would be extremely appreciated.
Our school is out for spring break and I haven't hear back from any of the instructors on this question. Thanks in advance!
Skin, hair, and Nails:
Pink, soft, dry, and very warm with poor turgor. Temperature of 100.1. Nails without clubbing, fingernails have raised ridges, and firmly adhered to nail bed. Capillary refill X 6 seconds. Pedal pulses not palpable without Doppler. Skin on feet red and shinny with no edema noted with exception of right great toe. Multiple blisters on both feet distally. Left great toe is swollen and the nail bed is hard but missing any form of a nail, possibly removed. First phalanges bilaterally cross under the second, possibly due to arthritis which also has caused deformities in the joints of her hands. Pt denies any pain or hx of arthritis. Pt. skin is in stage 2 decubitus in the perineum measuring approximately 1.5" each direction from midline laterally, beginning approx 3" above the anus and continuing to the vulva where the excoriation ends. Hair is gray in color, has wavy soft texture and even female distribution.
Mar 20, '09
well it isn't a decube...i just didn't know the correct words for wet, red, raw skin. i had erythemic, escoritaed (raw) tissue. i was cleaning her after a bowel movement when i saw her rectum had prolapsed. this has been hard for me to document also. she is on the mental health unit for anxiety, tho i didn't see any. she has no h&p, the teacher said this floor often doesn't have one in the chart. she live in a different town, but their was no mental health unit their.
here is what i wrote on the patho part:
-major medical diagnoses and pathophysiology of each (not signs and symptoms and not copied from medical disctionary). explain in depth about each disease, even chronic diseases that are not the reason for admission. explain how the disease processes are related to each other when applicable. this must be in the student’s own words and not cut and pasted from the internet.
pt has anxiety related to the loss of her husband as caregiver due to his recent hospitalization. her husband has been her primary caregiver since her development of alzheimer’s dementia, onset unknown to me. alzheimer's disease is characterized by loss of neurons
in the brain. this loss results in atrophy
of the affected regions. amyloid plaques
, deposits of the amyloid-beta protein on the outside of the neuron, and neurofibrillary tangles
, twisted fibers of the microtubules in brain cells, are clearly visible by a microscope in brains of those affected post mortem. enzymes act on the amyloid precursor protein (app) and cut the protein forming pieces that make up the plaques, disintegrating the neuron's transport system. this basically is like mice in the walls eating away at the electrical system. at first only small hints of memory loss are noticed, but how to stop the progression or reverse the effects are not known to science at this time. there are drugs, like aricept, that this pt is on which may slow
the progression. pt’s feet were assessed by arterial doppler and found biphasic flow bilaterally with calcified plaques. biphasic flow is slower blood flow most commonly caused by peripheral artery disease. this lack of arterial blood flow to the feet would explain why her feet and toes have skin breakdown and cellulitis. also, i checked her shoes in her closet; they are very narrow in the toe area with inside seams protruding. this may be where the pressure points began, and with decreased blood flow and possible neuropathy, why her toes ended up in such a state seemingly without her knowledge. of course, now i am curious as to whether her dementia is of the alzheimer’s type or vascular. without a health history, i can only hypothesize. another cause of the dementia could be resulting from her only actual written diagnosis of a previous medical condition which came via her home med list, resistant chronic myelocytotic leukemia. the resistant stage of this leukemia occurs 3-6 months before the final onset of the blast crisis in which the patient usually dies. she does show a significant increase in bands (immature white blood cells) 9% , decreased wbc less than 3 thousand. with her fever one would hope her body would be mounting a defense of 10-20 thousand wbc, but it is not. her lymphocytes are decreased at 16%. i would suspect the lack sufficient red blood cells, hers are 2.99, would further reduce the oxygen to the brain cells, skin tissues and cells in her feet to promote healing. due to all these factors combined, i think she is at very high risk for infection due to her compromised immune system and that will be my highest priority nursing intervention for her.
Last edit by DaydreamerRN on Mar 20, '09
: Reason: spelling