PATIENT HEALTH ASSESSMENT Student’s Name: Antonina Polukhina
Date: 4/1/2015
Clinical Facility: NCMC

PHYSICAL ASSESSMENT: Patient Initials: S. E. Age: 58 y. o. Sex: Female
Admitting Diagnosis: weakness/dizziness

Vital Signs: Temp. 97.4, Pulse 106, Respirations 18, BP 118/56
Ht/Wt/BMI: Height = 167.64 cm, Weight = 84.878 kg, BMI 30.2

Skin/Wounds: (Skin turgor; presence of any skin breakdown; incisions; wounds.)
Subjective: patient denies any skin breakdowns. Objective: leg skin is shiny and has several enlarged veins, otherwise, skin is pale and evenly pigmented, no lesions or excoriations, good turgor. Nails are light pink, adhere to nail bed with 160-degree angle. Hair is grey, shiny and full; amount and distribution
Activity Level: walker
Fall risk assessment: 11 (High risk)
Oxygen: room air
Side rail status: X2
Call light status: within reach
Pressure ulcer risk: 24 (No risk)

Medications (Include only prn’s that you administer)
Name
(generic/trade)
Dosage
Route
Frequency
Administration times
Atrovent (Ipratropium bromide)
0.5 mg/2.5 mL
HHN
q.4.h.
0700
1100
Ventolin (Albuterol sulfate)
2.5mg/3mL
HHN
q.4.h.
0700
1100
Zofran (Ondansentron)
4mg/2mL
IV
q.4.h. prn
0805
Ranolazine (Ranexa)
1,000 mg
PO
BID
0800
Ditropan (oxybutuin chloride)
5 mg
PO
BID
0800
Imdur (Isosorbide mononitrate)
30 mg (2 tabs)
PO
Daily
0800
Prednisone (Orazone)
20 mg
PO
Daily
0800
Norco (Hydrocodone acetaminophen)
325 mg
PO
q.4.h.
0800
Ditropan (Oxybutynin)
5 mg
PO
TID
1230
Neurontin (Gabapentin)
300 mg (2 caps)
PO
q.8.h.
1230

Intravenous Fluids
Time
Solution
Rate
Amt in bag
Site
Bag change due/time hung
Tubing type
N/A
NONE
N/A
N/A
N/A
N/A
N/A

Pertinent Lab & Diagnostic Test Results
Test
Result

INR
5.0 (H)

PT
54.3 (H)

X-ray
Mild cardiomegaly

PSYCHOSOCIAL/CULTURAL:
Primary & secondary languages: English.
Religious beliefs/spirituality/values: Christian.
Marital status: married.
Family/support system: husband, brother, friends.
Home/housing status: lives with her husband and