University:
Atlantic Cape Community College
Course:
NURS112 | Nursing II
Academic year:

2023
Views:

195

Pages:

2
Author:

Mariam Gould

HPI with OLDCARTS History of Present Illness for COUGH O: onset L: location D: duration C: characteristics A: associated symptoms/aggravating factors R: relieving factors T: treatment S: severity, setting Exercise #1: Identifying information-72 y.o. White female, born in the United States, married, retired school teacher Chief Complaint: Cough History of Present Illness: Onset-When did it start? How did it start? Was the onset gradual or sudden? Has it ever happened before? Location-N/A for cough Duration-Did it stop and start again or has it been continuous? Characteristics-Quality or Nature of the cough (dry, moist, productive, non-productive, moist, hacking, etc.) Color-(white, yellow, phlegm, mucous, purulent, blood tinged or frank blood) Odor Quantity or amount (over 25 hr-teaspoon, tablespoon, ¼ cup, etc.) Severity-does it tire you out? Does it interrupt sleep or conversation? Scale? Timing-(frequency), time of day, weather, activities Associated symptoms-Fever, chills, night sweats, sore throat, ear pain, chest pain, SOB, CP, chest tightness, PND, orthopnea, lower extremity edema, hoarseness, wheezing, gagging, choking Aggravating Factors-What makes it worse? Relieving Factors-What makes it feel better? Treatment-Is this your first time seeking medical attention for this problem? Prescription medications, Over the counter medications, Vaporizers, etc. Setting-indoors, outdoors; what were you doing when it started? Severity-How bad is it? Does it interfere with ADL? Pain Assessment- general guidelines ABCDE Pain Assessment A= Ask about pain regularly Assess pain systematically (scale 1-10) B= Believe the patient and family in their reports of pain and what relieves it. C= Choose pain control options appropriate for the patient, family, and setting. D= Deliver interventions in a timely, logical, and coordinated fashion. E= Empower patients and their families. Enable them to control their course to the greatest extent possible Skin ABCDE Assessment for malignant melanoma A= Assymetry B= Border irregularity C= Color, change or 2 colors D= Diameter > 6mm E= Elevation

Oldcarts Pain Skin - Reviewer Lab

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