\n\nSubjective<\/h4>\nHPI: Ms. Jones presents to the clinic complaining of a headache and neck stiffness that begun two days after a minor fender bender. One week ago, she was a restrained passenger in a motor vehicle accident. She and the driver never emergent care after the accident. Two days later, she developed bilateral temporal dull ache and a stiff neck. The headaches last 1-2 hours. He has taken OTC 650mg Tylenol for pain relief. General: No weight changes, fatigue, weaknesses, fever, chills, night sweats. HEENT: no head, ear, eye,<\/p>\n<\/td>\n | \n Subjective This is what the patient states. Chief Complaint History of Present Illness (PQRSTU) Neurologic Subjective You should ask about headache, head injury, dizziness\/vertigo, seizures, tremors, weakness, incoordination, numbness or tingling, difficulty swallowing, difficulty speaking, patient-centered care (past history), environmental\/occupational hazards Past Medical History Hospitalizations\/Surgical History Social History Family History Current Medications Allergies Substance Use Physical Activity Diet<\/p>\n<\/td>\n<\/tr>\n |
\n\nObjective<\/h4>\nMs. jones is a pleasant 28 year old African American. While she appears uncomfortable, she is alert, well oreinted, and in no distress. he maintained eye contact in the interview: Head: Normocephalic and atraumatic. Eyes: bilateral with equal hair distribution. Neurologic: Intact sense of smell and symmetric left eye. Vision: 20\/20 (left), 20\/40 (right),. Results from fundoscopic exam shows sharp disc margin and no hemorrhages while right fundoscopic exam shows mild retinopathic changes. Patient has equal pupils. Rinne and Weber tests normal bilaterally. Neck with full ROM<\/p>\n<\/td>\n | \n Objective This is what the nurse observes or assesses. Mental Status See Chapter 5 Mental Health. Cranial Nerves See Chapter 24 Neurologic System for objective assessments below: Cranial Nerves 1-XII Motor System Muscles, Cerebellar Function Sensory System Anterolateral Tract, Posterior Column Tract Reflexes DTRs<\/p>\n<\/td>\n<\/tr>\n |
\n\nAssessment<\/h4>\nAcute post-traumatic headache following a low-speed motor vehicle accident where the patient was a restrained passenger.<\/p>\n<\/td>\n | \n Assessment This is the main problem\/concern\/nursing diagnosis. Remember, you are in the role of the RN so you do not have to come up with a medical diagnosis or differentials. Problem, Concern, or Nursing Diagnosis What is the problem? Related to Why do they have this problem? As evidenced by What subjective\/objective data shows that they have this problem?<\/p>\n<\/td>\n<\/tr>\n |
\n\nPlan<\/h4>\nEnourage patient to continue monitoring her symptoms and report any increase in frequency\/severity of headaches. Initiate treatment with Ibuprofen 800mg (orally) with food for next 5 days. Adjunt therapy of topical heat\/ice per comfort TID-QID. Educate patient on the need for emergent care For follow up, patient should come back to the clinic after two days to discuss the symptoms and have a CT scan or MRI.<\/p>\n<\/td>\n | \n Plan List your SMART goal\/goals for the patient and list the interventions the patient may need to address the problem listed in the assessment section.<\/p>\n SMART goal\/goals<\/p>\n These should be measurable goals for the patient based on the assessment.<\/p>\n Interventions<\/p>\n This should help to achieve the SMART goal\/goals listed. This may include medications, treatments, therapy, education, or referrals.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n |