Running head: QSEN 1

Health History/QSEN Assignment

Mariam Abed

Bryant & Stratton College

LPVN100: Health History/QSEN Assignment

Professor Kaleelah Branche

March 26, 2020

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The following information in this paper will include the client’s biographical data, chief

complaint, present illnesses, past medical history, medications, health maintenance, family

history, personal and social history, and review of systems, as well as a care plan specific to the

client and her chief complaint.

Section I: Biographical Date

Initials: M.S.

Age: 95

Date of birth: 12/17/1923

Birth place: Ohio

Gender: F

Marital status: Widow

Occupation: None

Language and communication needs: Primary language is English; no specific communication

needs

Section 2: Source and Reliability

Client provided some information; most sources were from patient medical chart. Client was not

a reliable source for some information.

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Section 3: Chief Complaint (CC)

According to client’s medical chart, client has had hypoxia with pulse ox of about 86% on room

air.

Section 4: History of Present Illness (HPI)

Onset: Client is a 95 years old female with severe dementia and essential hypertension, both of

which had been well controlled prior to admission in 2018.  She was admitted with atrial

fibrillation with rapid ventricular response and was also diagnosed with influenza A and

pneumonia, then discharged to a skilled nursing facility. Patient then had hypoxia with oxygen

saturation of 86% on room air and sent to emergency department and admitted for further

management. During last hospitalization the patient was not eating or drinking well. Now in

2020, she was alert and disoriented, not able to provide history at that time. seems delightful

when communicating, symptoms of fatigue appeared, alert and disoriented, client seems to not

be in pain, client has irregular heartbeat client is not aware of any diagnosed illnesses. No

respiratory distress, patient was aware that stomach hurt and needed to urinate. Patient knew

when she was full of eating. Has baby doll that she calls her sister. Source from Patient chart.

Section 5: Past Medical History (PMH)

According to client’s medical chart, past and present medical history include stroke, rheumatoid

arthritis, hypothyroidism, aortic stenosis, hypertension, vitamin B12 deficiency, dementia, A-Fib,

congestive heart failure, fatigue, respiratory failure, and hypoxia.

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Section 6: Medication History/Current regime

Allergies: Allergic to Aricept and Exelon

Current Medications: Amiodaron, Metoprolol, Aspirin, Apixaban, Morphine Sulfate, and Ativan

Section 7: Health Maintenance

Clients last Immunization shot: Influenza: 10/05/2017

PPSV23 Pneumovax23 and PCV13: Denied 10/07/19

PPSV23 Pneumovax23 and PCV13: 10/07/2017

TB 1 Step Mantoux (PPD): 06/7/2018

TB 2 Step Mantoux Skin Test (Step 2): 06/14/2017

Last Examination:

BP-142/64, Pulse-54, Temp-Pt. Refused, Resp-16, Pulse Ox-86% on room air Ht- 5’1” (1.55m)

Constitutional: She appears content and pleasantly confused during conversation, neat in

appearance.

Patient sitting in chair, minimal tachypnea noted

Head: Atraumatic

Mouth/Throat: Oropharynx is clear and moist. Mucous membranes are pink and moist.

Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light.

Neck: Normal range of motion, Neck supple.

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Section 8: Environmental Health

Environmental past is unknown, unable to obtain information from patients’ severe dementia.

Section 9: Family History

Father: No known illnesses

Mother: No known Illness

Children: No kids

Section 10: Psychosocial History

Marital Status: Widow, Support system includes nieces and nephews.

Living Conditions: Client lives in Brentwood Health Facility

Client is not a full cognitive state and is not capable of answering things such as, education,

employment, or Signiant life events.

Drugs, Alcohol- No known alcohol or drug use

Nutrition, Sleep, Activities: Client eats what facility offers, last meal documented, eggs, toast,

cup of orange juice. Client goes to activities like bingo, or music class but does not participate.

Client sleeps on and off throughout day.

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Section 11: Spirituality

Religion: Catholic

Section 12: Sexual History

Unknown

Section 13: Review of Systems

Skin, hair, and Nails: Pink, soft, dry, and cold with poor turgor. Temperature of 96.2. Nails

without clubbing, fingernails have raised ridges, and firmly adhered to nail bed. Capillary refill

X 3 seconds. Pedal pulses palpable. Skin on feet red and shiny with slight edema +2 noted.

Multiple blisters on both feet distally. The nail bed is hard but not missing any form of a nail.

First phalanges bilaterally cross under the second, possibly due to arthritis which also has caused

deformities in the joints of her hands. Pt complains of joints of phalanges locking causes pain. Pt.

2 hemorrhoids present around anus. Hair is blonde in color, has wavy soft texture and even

female distribution.

QSEN:

Factors or solutions that would improve the patient’s situations with tactics of patient centered

care could include routine visits with the appropriate healthcare providers to ensure the patient is

taking her medications as prescribed and adjust those medications if needed. These visits will

also be used as a measure from the patients baseline to assess for improvement or deterioration

that may warrant interventions to ensure the patients comfort while in hospice. The patients

nursing facility is a factor that should improve her situation; she partakes in daily activities such
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as music and bingo but could benefit from attending therapy sessions; which she currently does

not.

We can recognize the patient as a source of control and a full partner in wellness by ensuring that

she is at an appropriate stage according the Maslow’s hierarchy of needs and has reached self-

actualization. If she is in “despair,” we can implement interventions to improve this, such as

reminiscing techniques and looking back at life with positive energy as much as

tolerable/possible for the patient given her history of dementia.

2. Teamwork and Collaboration

a. solutions that would improve the patient’s situation with tactics of collaborate can in include

the use of “memory care” professionals, therapists, a primary care provider, and other pertinent

providers.

b. functioning effectively within all teams, fostering open communication, and sharing decision

making will achieve a higher quality of care because they will all be aware of her current plan of

care and revise as needed, according to the patient’s status.

3. Evidenced based practice:

a. Evidence based practice is crucial in the health care environment and has been shown to be

effective when caring for patient needs. The NICE guideline has stated the use of psychological

intervention for patients with dementia. These include cognitive behavioral therapy, which will

include the patient’s cares, animal-assisted therapy, reminiscence therapy, multisensory

stimulation and exercise. [ CITATION The15 \l 1033 ] Evidence based practice can be approached by

those that are involves the individual and caregiver in establishing goals for care, communication
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of information about the patient, creating a strong team with aptitudes in dementia care and

implementing evidence-based models of practice [ CITATION Nan18 \l 1033 ] Evidence based

practice consists of using your expertise, patient preference and values and a problem solving

approach to clinical practice to make decisions about patient care. Evaluate the outcome of the

new actions. With my patient in hospice there’s only so much the health care givers can do for

her health, the plan would be to make her the most comfortable she can be with an aggressive

disease that is affecting her cognitively, and physically. Helping patient be at ease with uses of

medications does not cure dementia but can prolong the disease. Encouraging the patient to

participate in activities even though she is too advanced in the disease she wouldn’t know how to

participate still can have positive effects on her comfort and happiness. Often patient will hold a

doll to try to activate a response associated with caregiving, attachment and emotion, patient

often calls doll her sister, ultimately bring some level of comfort and joy [ CITATION Kri \l 1033 ]

4. Quality Improvement:

a. factors or solutions that would improve the patient’s situation by changing aspects of her

environment, systems or treatment could be behavior therapy such as involving the patient in

meaningful activity. Patients with dementia are at risk to losing out on enjoyable moments so this

can be a crucial intervention to prevent feelings of hopelessness or depression. Environment

modifications that support safe facilitation with activities of daily living help with quality of

living.

5. Safety
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a. since this patient suffers from dementia, she is at a high risk for dangers to herself with her

confusion and loss of memory. Safety and security of her environment is important, and although

she is a generally safe environment of the nursing home; caregivers should still take extra

precaution to ensure that her room environment is safe and reorient her as necessary.

b. As my patient has dementia, I believe she feels confused, agitated, and feels hopeless on a

condition that’s at a point where she may not know that she has been diagnosed with now.

Treating her symptoms on time daily with medications prescribed to her is crucial, and to all

patients who have been prescribed medications. Licensed Health Caregivers can only help the

patient’s safety by communicating with their colleagues on Medication administration and

dosage.

We can see that failing to give patients medications on time daily means health care

givers may not be communicating about the importance of medication administration for their

patients and the poor acts can lead fatal outcomes to despair. As a future health care giver, I

believe caring for my patients means communicating, maintaining homeostasis and keeping my

patients safe from harm are my priority. Sustaining homeostasis and keeping your patient safe

are important components and acts that Licensed health care professionals should seek to uphold

and desire.

6. Informatics
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Nurse informatics specialists are an integral part of the healthcare delivery process and a

deciding factor in the selection, implementation and evaluation of healthcare, which supports

safe, high-quality and patient-centered care (Elkind, 2009) Informatics by nurses can also be

defined as enhanced patient outcomes, and throughout the healthcare facility to nursing

education and research. Using informatics, we can see how much the disease has progressed.

Relevant factors commonly associated with AD in the published literature were derived from

health or medical history, age, sex, history of alcohol abuse, history of smoking (current or

former)[ CITATION Jou16 \l 1033 ]

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References

Hillis, K. (n.d.). Brain Test. Retrieved from https://braintest.com/dolls-dementia-nursing-home-

went-viral/

Journal of Women & Aging. (2016). Retrieved from https://c-path.org/wp-

content/uploads/2016/09/ronquillo_baer_lester_-_2016_-_sex-
specific_patterns_and_differences_in_dementia_and_alzheimers_disease_using_informat
ics_approache.pdf

Nancy A Hodgson, P. R. (2018, January 18). The Gerontologist. Retrieved from

https://academic.oup.com/gerontologist/article/58/suppl_1/S129/4816738

The Writer Pass Journal. (2015). Retrieved from

https://writepass.com/journal/2017/02/evidence-based-interventions-for-a-patient-
suffering-from-dementia/