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Complex Assessment: Arrhythmia Results | Turned In
Spring 2025 LPN-Acute & Chronic NURS-4766-4490, 730676
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Overview
Transcript
Transcript
Subjective Data Collection Started: Apr 08, 2025 | Total Time: 99 min
Objective Data Collection All Lines (109) Interview Questions (57) Statements (2) Exam Actions (50)
Education & Empathy
Documentation Hello.
Stroke Scale Activity Que
What brings you in?
04/08/25 7:35 PM
Suspected Problem
Stroke Team SBAR Well, there's a laundry list. What concerns me most is how short of breath I've
been, how heavy my chest feels.
Reflection
Thank you for saying that.
Que
Do you know where you are?
04/08/25 7:36 PM
Of course. I'm at Shadowville General Hospital. My nieces and nephews were
born here.
Que
What time is it?
04/08/25 7:36 PM
Yes, it's [Mr. Francis reports the correct time].
Que
Can you tell me your name?
04/08/25 7:37 PM
Martin Francis.
Que
Do you know why you are here?
04/08/25 7:37 PM
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Yes, I'm here to be treated for this . . . business I've been dealing with.
Are you in pain?
No, I'm not in pain. Though, there is a level of discomfort that accompanies the
heaviness in my chest.
Do you have any cultural or spiritual needs>
I don't require any special accommodations, but you are right for asking.
When did symptoms begin?
I've been feeling sick for the last forty-eight hours, but my rapid heartbeat,
shortness of breath, and chest heaviness started getting worse in the hour before
we came here.
When did your systoles worsen? (No matching questions found.)
No matching questions found.
When did your symptoms worsen?
Well, it was sudden when it happened. Two days ago, I started to feel this way,
the shortness of breath, the chest heaviness, the rapid heartbeat, the dizziness.
An hour ago, just before I decided to come here, the symptoms became worse.
Did anything aggravate your symptoms? (Clarified to Did anything trigger your
symptoms?.)
Activity of any kind makes it all worse. Then, when I lie down, just to have a little
reprieve, I can hardly breathe. The symptoms are constant. (Clarified to if
anything triggered my symptoms.)
Does resting relieve your symptoms?
Yes, I rest every so often, and it does help a little.
What treatment have you tried?
I find resting relieves my shortness of breath and the chest heaviness a bit. I have
been resting when I can, but I haven't taken any medication to treat my
symptoms.
What treatments have you tried?
I find resting relieves my shortness of breath and the chest heaviness a bit. I have
been resting when I can, but I haven't taken any medication to treat my
symptoms.
When do your symptoms occur?
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Activity of any kind makes it all worse. Then, when I lie down, just to have a little
reprieve, I can hardly breathe. The symptoms are constant.
What existing health conditions do you have?
I have high blood pressure, high cholesterol, and diabetes.
DO you have any allergies?
I don't have any allergies that I know of. I'm not allergic to any foods, medications,
or seasonal things. No latex allergy, either.
Do you have any previous hospitalizations?
I've never needed to be hospitalized.
Any history of surgeries?
No, I've never had surgery.
Are your parents living?
No, both my parents are no longer with us.
Does your mother or father have health problems?
My parents passed some time ago. I know my father had hypertension and my
mother had diabetes.
How did your parents pass away>
My mother died of natural causes, and my father passed away after having a
stroke.
Do you take any home medications? (Clarified to What medications do you
take?.)
I take medication for diabetes, high cholesterol, and hypertension. (Clarified to
what medications I am taking.)
Do you take diabetes medications?
I take 10 mg of extended-release glipizide for my diabetes.
Do you take heart medication?
I take my high blood pressure medication every day, as directed by my doctor. I
do my best to adhere to the regimen.
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