I. Data Collection History of Present Problem: Julie Wilson, a 48-year-old female, brought into ER by husband after she

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I. Data Collection
History of Present Problem:
Julie Wilson, a 48-year-old female,
brought into ER by husband after she collapsed at home this
am. Initially was slightly confused. Complaining of
severe right temporal lobe headache and blurred vision.
Husband reports that she was complaining of headaches and blurred
vision that “came & went quickly” over the past 3-4 weeks. CT
w/o contrast of right temporal lobe positive for ischemia. Treated
in ICU with rTPA. Residual left sided weakness noted. Patient
transferred to med/surg floor to begin rehabilitation and for blood
pressure stabilization. Patient noted with edema of bilateral lower
extremity upon assessment by the med-surg nurse.
PMH: HTN, Diabetes – type II, hypercholesterolemia, ½ ppd smoker
and peripheral vascular disease (PVD).
Personal/Social History:
Married for 20 years. Has 3 children who are grown and on their
own. Patient works in human resources at a local supermarket.
Exercises a couple times a week.
What data from the histories is important &
RELEVANT; therefore, it has clinical significance to the
nurse?
RELEVANT Data from Present Problem:
Clinical Significance:
RELEVANT Data from Social History:
Clinical Significance:
What is the RELATIONSHIP
of your patient’s past medical history (PMH) and current
meds?
(Which medication treats which
condition? Draw lines to connect.)
PMH:
Home Meds:
Pharm. Classification:
Expected Outcome:
HTN
Diabetes Mellitus
Peripheral vascular disease (PVD)
Metoprolol (Lopressor) 50mg daily
Metformin 500mg daily
Cilostazol (Pletal)
II. Patient Care:
Most Recent
VS:
WILDA Pain Assessment (5th VS):
T: (oral) 99o F
Words:
No Pain
P: 102
Intensity:
n/a
R: 22
Location:
n/a
BP: 174/104
Duration:
n/a
O2 sat: 96% on RA
Aggravate:
Alleviate:
n/a