HEad to toe assessment

Focused Assessment, ROS, and Cultural Assessment

Svetlana Alpin

Broward College

Focused Assessment, ROS, and Cultural Assessment

CHIEF COMPLAINT

The patient is presented to the clinic with complaints of itchiness and tingling sensation in her mouth that seems to be increasing in severity with time.

HISTORY OF PRESENT ILLNESS

Ms. A. is 32 years old, an Asian female with no known drug, food or environmental allergies presented today with a strange feeling in her mouth which increasingly became an itchiness in her throat with a tingling sensation in her mouth. The problem began in the last one hour and seem to be increasingly symptomatic of a problem with time. She claims as she continued eating a fruit salad, she started scratching herself more and coughing which shifted in wheezing. She denies being under any medication and states that she has experienced a similar issue earlier on in the year while having a cake. She reports that the irritation to her skin seems to be at a pain level of 4/10 but increasing with time. The patient began vomiting while in the waiting area with mild stomach pains and dizziness. She also says that she feels like there is tightness to her throat (Fletcher & Gill, 2018).

MEDICATIONS

Natural Supplements for Iron

No formal medication

ALLERGIES: allergic to strawberries, no known environmental or drug allergies.

SOCIAL HISTORY

Tobacco Use: none

ETOH use: none

Illicit drug use: none

Born in: Seoul, Korea

Education: Undergraduate Business Administration

Occupation: Office Manager

Family Situation: Single

Interest/Hobbies: Travelling, cooking, playing outdoors

PAST MEDICAL HISTORY

Appendicitis in 2014

Eczema in 2005

PAST HOSPITALIZATIONS

Hospitalized for appendicitis in 2014

Hospitalized for broken bones after an accident in 2017

PAST SURGICAL HISTORY

Plastic surgery for nasal cavity repair in 2017

Appendectomy 2014

VACCINATIONS

Flu: none

Pneumovax: not applicable

Tetanus: April 2017

FAMILY HISTORY:

Father: alive; healthy

Mother: alive; diabetes, Hypertension, eczema

Grandparents: deceased

Paternal grandfather: deceased heart attack.

Paternal grandmother: from lung cancer

Maternal grandfather: deceased, car accident

Maternal grandmother: deceased from complication due to diabetes.

Siblings: An only child

Children: none

REVIEW OF SYSTEM:

CULTURAL ASSESSMENT:

Patient, Mrs. A., is a 32-year-old singe Asia female. English-speaking, literate in reading and writing; talkative, open, and cooperative. The patient is of Korean descent, born in Seoul, Korea and raised in California, USA. Patient values education, financial resources, and family which are elements she attributes to her have a quality life. She loves working as an office manager. She loves food and has passion in culinary arts that she can only explore through critiquing in her spare time. She is an atheist and therefore doesn’t conform to any particular school of thought on religion. She doesn’t have any children and she does not see nay in her future. She has recently taken to sampling different kinds of food from South America which have been heavily centered on fruit choices. She avoids taking medication but believes in supplements as part of the necessity in her health.

NANDA #1

Risk for ineffective breathing pattern related to allergic reaction as evidence by patient stating that her throat feels tight.

NANDA #2

Impaired oral mucous membrane and skin integrity related to food irritants as evidenced by skin itching and hives.

PLAN OF CARE:

Anti-allergy injection and communication of the finding of the assessment to the MD. Medicate the patient for the symptoms and pain as ordered, and reassessment of the situation after a few days. Provide a comfortable and relaxing atmosphere by setting the patient in a comfortable chair an offering somewhere to vomit. Letting the patient talk as much as possible to take away her focus on scratching her skin. Make sure that the environment is free of any stimuli with relative humidity. Follow the orders for allergy test confirmation and diagnostic examinations upon prescription (Jensen, 2015).

References