Biographic Data:

Name: Elizabeth Diaz

Sex: Female

Date of Birth: October 02, 1936

Address: 6 Dogwood Course Ocala, FL 34472

Marital Status: Widow

Source: Patient

Shift Complaint: Severe middle back pain 8 out 10, and a red, itchy rash around the back that does not go away with aloe lotion or hydrocortisone.

History of present illness: Patient started having moderate to severe middle back pain (6 out 10) that would go away with Tylenol or Ibuprofen. The onset for the pain was 6 days ago and the patient assumed it would eventually get better, but it did not. After four days of not making any improvement, the patient noticed blisters on the same area she was having the pain, which turned to a very itchy rash. She also reported frequent headaches and fatigue.

 

Past Health History:

Childhood Illnesses: Strep throat x 2 and Tonsillectomy when she was 4 years old. All childhood immunizations up to date. Chickenpox at age 7 and Mononucleosis at age 12.

Accidents: Car accident with no serious injuries at age 31.

Surgeries: C section x 2 (1964 and 1967) and Cataract surgery 2013.

Hospitalizations: C section (1964 and 1967).

Medical Conditions: Diabetes type II, Hypertension, GERD, and Hypothyroidism.

Obstetric History: Gravida 2, Parity 2

Last examination: Colonoscopy and upper endoscopy, January 2015. Pap smear and wellness physical with blood work, December 2015.

Allergies: Penicillin -anaphylactic reaction

Alcohol Intake: Occasional red wine

Tobacco Use: Current smoker, 10 cigarettes per day

Coffee Intake: One cup a day

Exercise: Reported 20 minutes’ walk ever day

Illicit Drugs: None

Current Medications:

Metoprolol 50 mg every morning to treat hypertension

Metformin 500 mg twice a day to treat Diabetes type II

Levothyroxine 75 mcg every morning to treat hypothyroidism

Omeprazole 40 mg every morning to treat GERD

Melatonin: 10 mg at bedtime as needed to treat insomnia

 

Measurement:

Height: 5.2 inches         Weight: 146 pounds                BMI: 26.7

BP: 142/87       T: 98.7 F         RR: 19 unlabored           O2 sat: 98%              HR: 77, regular

Pain level: 6 out 10. Middle back pain

 

Review of Systems:

General Health: Reported to feel in pretty good shape before this new onset of symptoms. Denies fever, unintentional weight loss, bleeding from anywhere or any other complains.

Skin: Sagging skin noticed around the upper eyelid. Two small shiny bumps on the forehead. Red and itchy rash around the middle back that causes severe pain. The rest of the skin appears to be dry and intact.

Head: Frequent headaches that mimic migraines. Denies seizures, numbness, tremors, or dizziness. Even hair distribution. Symmetric face expression. 

Eyes: Patient wears reading glasses. Currently, she denies blurry or double vision. History of cataract surgery 3 years ago on both eyes. Pupils equal, round and reactive to light and accommodation.

Ears: Denies hearing loss or difficulty. Skin color tympanic membrane, with no signs of inflammation, redness or pain. No discharge noted.

Nose: Normal nasal mucosa, with no crusting, nasal polyps, epistaxis, septal deviation or perforation signs. No pressure or tenderness around the sinuses.

Mouth and Throat: No mouth lesions, toothache or throat pain noted upon examination. Midline uvula and tonsils removed. Staining teeth due to current coffee and tobacco use.

Neck: Full range of motion. Reported occasional stiffness due to suspected arthritis and use of a thick pillow every night. Midline trachea and palpable carotid pulse.

Upper extremities: Symmetrical appearance and full range of motion and muscle strength of hands, wrists, arms, and shoulders. Radial and brachial pulses compared.

Breast: No lumps, redness, tenderness, nipple discharge or indentation was noted upon examination. Patient reported not to be compliant with her self-breast exam. Denies any history of family breast cancer. Last mammogram with not abnormal findings was done 10 months ago.

Respiratory: Denies shortness of breath. Bilateral clear lung sounds upon auscultation. Occasional early morning cough related to smoking 10 cigarettes a day. Failed to smoking cessation twice within the last 5 years.

Cardiovascular: Denies chest pain or palpitation. Auscultated apical rate and rhythm.

Gastrointestinal: Normal active bowel sounds. Denies epigastric pain, diarrhea, or nausea. No hernias noted upon palpation of all quadrants. Liver and spleen palpated.

Lower extremities: Symmetrical appearance and full range of motion. Popliteal, posterior tibial, and dorsalis pedis pulses palpated.

Genitourinary: Denies dysuria, hematuria, or any difficulties to urinate. No history of kidney disease or kidney stones.

Neurologic: Denies tingling, numbness, or paresthesia. No history of seizures, strokes, or fainting. All reflexes intact. No weaknesses, or difficulties talking or swallowing. Denies depression and or suicidal thoughts. All cranial nerves checked with no abnormalities.

Musculoskeletal: Mild to several middle back pain and neck stiffness. No deformities or history of arthritis.

Endocrine: No palpable masses, or tender/firm lymph nodes. Maternal grandmother and her own daughter with Diabetes Mellitus type II. Patient reported no increased in hunger, thirst, or urination.

Genitalia: Menarche at age 13. Last period reported about 26 years ago. No vaginal discharges, itching, or lesions upon examination.

 

Functional Assessment:

Self-concept: Housewife and widow for about 19 years. Raised as Baptist, believes in God. Lives alone, and performs all daily activities independently. Believes limitations are smoking and weight.

Activity-Exercise: Reported to do a 20 minutes’ walk every morning. No mobility aids. No sustained physical exercise.

Sleep pattern: Bedtime 10:00 pm. Sleeps between 7 and 8 hours. Uses Melatonin sporadically.

Nutrition: Drinks whole milk and does not eat enough greens, such as spinach or green beans. Reported to be somehow compliant with a diabetic diet. Only uses Splenda and does not drinks sodas. No food intolerance.

Interpersonal relationships: Describes her family as her number one priority. Gets along well with everybody and enjoys spending time with grandbabies when possible.

Coping and stress management: Uses music as a therapeutic way to release stress. Considering smoking cessation again, and believes prayers can make a difference in her life.

 

 

 Genogram

Mother side:

Grandmother: Hypothyroidism, Hypercholesterolemia, and Diabetes Type II

Mother: Hypertension and Diabetes Type II

Uncle: Glaucoma

Aunt: Unknown

 

Father side:

Father: Alcoholism and Vitiligo

Uncle: No known conditions

Uncle: Hypertension and Alcoholism

Aunt: Melanoma skin cancer

Son: No known medical conditions

Daughter: Bipolar disorder and Diabetes Type II

Brother: Alcoholism

Sister: No known medical conditions

Nephew: Epilepsy

Niece: ADHD

 

Assessment:

Tested positive for Shingles

Hypertension

Diabetes Mellitus type II

Hypothyroidism

GERD

 

Nursing Diagnosis:

1) Knowledge deficit related to lack of information about Shingles

2) Acute pain related to the presence of lesions and pruritus

3) Risk for infection related to open oozing area on the middle back

4) Self-care deficit related to inadequate sun exposure, lack of exercise, non-compliant with self-breast exam, and failure to smoking cessation twice.

 

Nursing Intervention:

• Describe the nature of the disease, possible causes, and the importance of not spreading the disease and following the treatment.
• Take medications as prescribed for itching and pain.
• Refrain yourself from direct contact with other until the sores are covered with scabs.
• Maintain adequate hand hygiene to prevent spreading the virus.
• Wash any soiled cloths and linen with hot water and soap.
• Wear clean cotton undershirt every day.
• Make a follow up appointment and provided and number to answer any questions or concerns the patient may have.

 

Overall health:

• Consider smoking cessation along with professional counseling.
• Wear sunscreen and get a screening cancer for skin cancer at least once a year
• Perform monthly self-breast exam to prevent breast cancer
• Increase your calcium intake and consider a low fat diet (2% milk instead of whole milk)
• Join an exercise program for seniors around your community.