Validation #3 Graded Documentation Sheets

To be completed following Validation #3 and submitted for grading immediately following the SP interaction. Please document in black ink only.
If you make a mistake in document, please draw one line through the mistake, initial, and date.

Biographical TH is a 54 year old female, DOB 4/13/1965. Patient seems reliable.

Past Medical Discharged from hospital yesterday with acute exacerbation of COPD with bronchitis. Denies previous HTN, cardiovascular disease,
History diabetes, stroke, or cancer.

Mental Health Denies history of anxiety, depression, or psychosis. Denies previous suicide ideations or attempts. Denies history of other mental
History illnesses.

Past Surgical
History Denies history of any childhood or recent surgeries.
Family History Denies family history of HTN, cardiovascular disease, diabetes, stroke, or cancer. Reports parents and siblings are alive and well.

Social History Reports quitting smoking 5 years ago after smoking 2 packs a day for 20 years. Denies use of alcohol or illicit substances. Reports being
too busy to engage in social interactions with friends. She lives alone with no significant other.

Environmental
or Risk Factors Denies being exposed to air pollutants, chemicals, and excessive sunlight. Reports a diet that is low fat and low carb. Reports being too
busy to exercise weekly. Reports being unable to sleep due to hospital monitor sounds last night, but is generally able to get a good
night’s sleep.
Review of Systems Interview and Physical Assessment
VITAL SIGNS P: 76bpm RR: 16 T: 36.2 C BP: 122/92 arm: Right Pain: 0/10 Height: 5’4” Weight: 149lbs BMI: 25.6 SpO2: 97% on 2L nasal
cannula, 86% on room air
General S: TH reports SOB that has not gotten better since being discharged yesterday. SOB is exacerbated with ambulation and relieved for a few
hours after ipratropium treatment. TH denies pain with the SOB, but reports a “smoker’s cough” every morning with thick, yellow phlegm
 that has gotten worse over the week to the point where she is coughing throughout the day. She reports having a nasal cannula, but does
not wear it during ambulation because she “doesn’t like wearing the tubing”.

O: Appears to be her stated age. TH is awake, alert, and attentive to surroundings. Skin is evenly toned without apparent lesions. Facial
features and limbs are all symmetrical bilaterally and maintain range of movement without apparent physical deformities. Appears
within normal height for her age, and slightly overweight viscerally. Posture is straight without apparent spinal deformities. Gait is
smooth and balanced without assistance. Appears to have full range of motion in all joints. Able to maintain eye contact. Attire is clean
and appropriate for the season. Exhibits signs of good hygiene including groomed hair and no detectable body odor. Denies current
suicidal, depressive, or anxious thoughts. Reports looking forward to retirement.

Integumentary S: Denies recent hair loss, dry or flaky skin, and skin or nail discolorations.

O: Skin is dry, intact, and dark brown with an even tone throughout the body, consistent with ethnicity. Hair is dark brown and coarse
without excessive oil, evenly dispersed over the scalp and body. Skin temperature is warm with good turgor. Nails are dark pink, short,
and slightly curved. Skin is generally free of rashes or lesions.

HEENOT S: Denies recent history of H/A, dizziness, sore throat, or facial pain.

O: Head appears normocephalic without facial lumps or lesions. Denies pain or pressure when palpating frontal, ethmoid, and maxillary
sinuses. Denies tenderness when palpating temporal area. Temporal artery is palpable and has a +2 pulse. Nose appears symmetric
without lesions or bumps. Nares are patent with pink, moist turbinates absent of lesions. Exudate is absent and the septum does not
deviate. Negative for crepitus or clicking when maneuvering mandible. Both outer and inner lips are even-toned, moist, without apparent
lesions or masses. Buccal tissue is brown and moist without apparent lesions or bumps. Gums are pink and negative for signs of
inflammation. Teeth appear to be all present without signs of malocclusion or wearing down. Hard palate is dark pink, absent of
abrasions. Soft palate is darker pink and smooth. Tonsils +2, pink and absent of bleeding or bumps. Uvula rises midline upon speaking.
Frenulum present. Tongue is pink and absent of obvious abrasions, discoloration, or candida. Tongue does not deviate to the side.

Neck, including S: Denies swelling or pain in neck. Denies noticing swollen lymph nodes. Denies recent history of infection.
lymph nodes
O: Lymph nodes are not palpable. Neck and head retains full ROM. Carotid pulses palpable, +2 bilaterally without bruits. Trachea is
midline. Thyroid is equal bilaterally without evidence of bumps or masses.
Cardiovascular S: Denies chest pain or congestion. Denies cool, sweaty extremities, calf pain with ambulation, or pale fingers/toes.
& Peripheral
Vascular O: Negative for visible jugular distention. Absent of visible lifts or heaves. Pericardium appears even-toned and symmetrical in width and
depth without detectable lesions, masses, or concavities. Apical impulse palpable at 5 th intercostal space. S1 and S2 present with regular
rhythm. S3 and S4 are absent. Negative for heart murmurs.
Extremities are warm, same temperature as other areas of the body. Skin is consistent in texture and color with the head and torso,
negative for ulcers. Negative for edema in all four extremities. Palpable pulses in radial, popliteal, dorsalis pedis, and posterior tibial
regions, all +2 and equal bilaterally. Right index finger capillary refill less than one second.

Respiratory S: Reports current SOB and morning cough with thick, yellow sputum. Reports negative TB skin test this year. Denies recent history of
upper respiratory tract infections.

O: AP transverse diameter 1:2. RR 16 breaths per minute, evenly spaced. Chest expansion symmetric bilaterally posteriorly and
anteriorly. Tactile fremitus equal and bilateral. Chest is negative for masses or lesions. Percussion yields resonance throughout lung fields
posteriorly and anteriorly. Lung sounds are clear throughout lung fields posteriorly, laterally, and anteriorly without evidence of rales,
crackles, wheezing, or stridor. Negative for bronchophony and egophony.

Abdomen / GI deferred

Musculoskeletal deferred

Neurological deferred
 Genitourinary / deferred
Breasts
Endocrine deferred
Hematological deferred
Nursing Diagnosis Statements

First Priority Nursing Diagnosis Statement:

Ineffective breathing pattern R/T hypoxia AEB patient report of feeling “short of breath walking to the bathroom” and spO2 less than 86% on
room air.

Second Priority Nursing Diagnosis Statement:

Activity intolerance R/T compromised oxygen transport AEB patient report of “short of breath walking to the bathroom” and taking out her nasal
cannula during ambulation because she “doesn’t like wearing the tubing”.

Signature: ______________________________________ Date: 10/3/19

Printed Name: Gelsey Jian