IDENTIFYING SUBJECTIVE AND OBJECTIVE CUES FROM THE CASE STUDYSUBJECTIVE DATAOBJECTIVE DATA REVIEW OF SYSTEMSPsychologicalThe client views herself as a simple person, gifted with a peaceful life. Even though she lives all alone byherself, she thinks that it is good enough for her. Sometimes she feels lonely when listening to love songs since shenever had a chance to meet the man if her life. She also prefers to be alone for some time and does not wantto socialize when she is sad since most of her neighbor have their own family.EliminationThe client urinates 5-6 times a day scanty in amount, yellowish color with no accompanying discomfort.She defecates 2 times a week, brown in color, scanty in amount and is hard. According to her, this is the usualcharacteristic of her bowel. She perspires a lot.Rest and ActivityShe used to watch television and listens to the radio whenever she gets tired. Her usual activities of dailyliving Include cleaning her house, doing the chores and gardening. She expresses concern like learning simpleexercises that she can do inside the house but she does not know where or who to seek information.Safe EnvironmentMs. Sy feels secure in her place since the Barangay Hall is just adjacent to her house. According to her,she seldom hears troubles in their place since the Baranggay Tanods are very active. She lives in a house madeof concrete material. There are no allergies to food, drugs and to the environment.OxygenationShe does not have any signs of respiratory distress and never had symptoms of difficulty in breathing. CASE 5 - COMMUNITY CASE STUDYA. NURSING HEALTH HISTORYPersonal Data:Ms. Sy is a 65 years old, female, and residing at Quiapo, Manila. She is single, a Flipino citizen and a RomanCatholic believer. Her usual source of health care is at the Barangay Health Center.Chief Complaint:"My joints are painful and it seems so hard to move especially when I get stuck in one position andI don't know why."History of Present Illness:The client cannot remember the exact date when the symptoms started. But according to her it startedgradually since she turned 60 years old. The symptoms seem to worsen especially when it's cold at night.Past Medical HistoryMs. Sy had a complete immunization when she was a child. Common illnesses include fever, flu, thencough and colds, which are usually relieved at home. She never experienced any injuries. No records ofhospitalization and she does not take any form of medication.Family HistoryNo heredo-familial diseases such as asthma, diabetes, hypertension etc.Social HistoryShe lives alone in her house and believes in the effects of herbal medications. She does not have anysuperstitious belief that can affect her health status. Ms. Sy finished her primary education in Cebu and used towork as a sewer, up to present. According to her, she never had any conflicts with her neighbor. She also receivesmonthly pension from SSS and Philamlife.

Subjective patient data contains the health highlights concerning the patient viewpoint and…

Answered: IDENTIFYING SUBJECTIVE AND OBJECTIVE…

Science

Nursing

IDENTIFYING SUBJECTIVE AND OBJECTIVE CUES FROM THE CASE STUDY

Comprehensive Medical Assisting: Administrative and Clinical Competencies (MindTap Course List)

6th Edition

ISBN:9781305964792

Author:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa

Publisher:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa

Chapter5: The Therapeutic Approach To The Patient With A Life-threatening Illness

Section: Chapter Questions

Problem 5.1CS

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an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…
an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…
an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…
an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…
an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…
an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…
an afternoon shift. Patient informationName: Irene Smith Age / Sex: 16 years 10 months / femaleAccompanied by: Taylor Smith (Brother, 20 years/Male)Present Medical HistoryIrene presented to the PED with her brother Taylor, following a fall around 3 hours ago. Irene was riding abike in in the street in front of her home and bumped into a parked car on the street, fell and hit her head.She was not wearing a helmet during the incident. There was no loss of consciousness noted at the time.However, she started having headache after half an hour of injury. There were multiple abrasions on elbowand knee and swelling on her left forehead.Past Medical/ Surgical HistoryAcne Vulgaris, Depression, Anxiety, and attempts of self-harm multiple timesCurrent medications: Roaccutane, Olanzapine (poor concordance- she misses to take medicationsregularly as prescribed)Allergies: Pea nuts (Anaphylaxis)Perinatal historyVaginal birth, other details are not availableImmunisation history? Incomplete. Irene…
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