evaluate the attachment that’s an instance of what i want.
Directions:
Make an entire historical past and bodily examination in a complete method with all its components included: CC, HPI, PMH, FH, SH, MEDICATIONS, ALLERGIES, ROS PER APPARATUS OR SYSTEMNS, HEAD TO TOE PHYSIACL EXAMINATION PER SYSTEMS ( write your presentation in H&P format no paragraph format).
Primarily based on this data, what’s your presumptive nursing analysis? All nursing analysis that apply to the case (Minimal three) written in NANDA format associated to … and proof by…., NO MEDICAL DIAGNOSIS.
Educating plan and nursing care plan per every nursing analysis on this case.
Necessities.
1- All written task and documentations should be in APA sixth version format.
2- Double areas, minimal four pages lengthy , minimal three updated bibliography. (UP to this point means final three years.), Notice: you should utilize your take a look at guide as bibliography too, bibliography must be written in APA format.
Case Study II
Jessica is a 32 y/outdated math instructor who presents to the ER with a buddy for analysis of sudden lower of imaginative and prescient within the left eye. She denies any trauma or damage. It began this morning when she awoke and has progressively worsened over the previous few hours. She had some blurring of her imaginative and prescient 1 month in the past and thinks which will have been associated to getting overheated, because it improved when she was in a position to get in a cool, air-conditioned setting. She has some ache if she tries to maneuver her eye, however none when she simply rests. She can also be unable to find out colours. She denies tearing or redness or publicity to any chemical compounds. Nothing has made it higher or worse.
She is generally wholesome. She had chickenpox at age 10 and a tonsillectomy/adenoidectomy at age 11. She has no medical issues. She has by no means been hospitalized. She has 4 kids, all spontaneous vaginal deliveries. She accomplished a bachelor’s diploma in arithmetic and a grasp’s diploma in training. She stop smoking 10 years in the past (two packs each day for five years); she drinks an occasional wine cooler, and he or she denies illicit drug use. Her father has a coronary artery illness (he had a stent positioned at age 67) and a mom with hypertension.
She denies fever, chills, night time sweats, weight reduction, fatigue, headache, adjustments in listening to, sore throat, nasal or sinus congestion, neck ache or stiffness, chest ache or palpitations, shortness of breath or cough, stomach ache, diarrhea, constipation, dysuria, vaginal discharge, swelling within the legs, polyuria, polydipsia, and polyphagia.
Affected person is alert; she seems anxious. BP 135/85 mm Hg; HR 64bpm and common, RR 16 per minute, T: 98.5F. Visible acuity 20/200 within the left eye and 20/30 in the best eye. Sclera white, conjunctivae clear. Unable to evaluate visible fields within the left facet; visible fields on the best eye are intact. Pupil response to gentle is diminished within the left eye and brisk in the best eye. The optic disc is swollen. Full vary of motions; no swelling or deformity. Psychological standing: Oriented x three. Cranial nerves: I-XII intact; horizontal nystagmus is current. Muscle tissues with regular bulk and tone; Regular finger to nostril, damaging Romberg. Intact to temperature, vibration, and two-point discrimination in higher and decrease extremities. Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achiles tendons; no Babinski.
