NUR 600 Assignment 3.1: Review of Systems (ROS) Documentation

Sample Answer for NUR 600 Assignment 3.1: Review of Systems (ROS) Documentation

General: He reports mild fever and increased fatigue. Negative for chills or weight changes. 

 Skin: Negative for skin-color changes, itchiness, rashes, or bruises

 HEENT: Head: Negative for headaches or head injury. Eyes: Reports itchy eyes. No visual loss, blurred vision, double vision, or yellow sclera. Ears: Reports itchy ears. No ear discharge or hearing loss. Nose: Positive for itchy nose, sneezing, nasal congestion, rhinorrhea, and postnasal drainage. No nasal bleeding. 

Throat: Positive for itchy palate. No sore throat or swallowing difficulties.

 Neck: No neck pain or stiffness.

 Respiratory: No cough, sputum production, shortness of breath, or chest pain.

 Cardiovascular: Negative for edema, palpitations, chest pain, chest pressure/discomfort, SOB on exertion, or fatigue.

 Gastrointestinal: No nausea, vomiting, epigastric pain, bloating, abdominal pain, diarrhea, constipation, tarry stools, or rectal bleeding.

Urinary: No dysuria, urinary frequency, urgency, blood in the urine, or abnormal urine color.

 Genital: Negative for penile discharge, testicular pain, or scrotal swelling. He denies a history of STIs.

Peripheral vascular: Denies having leg cramps, swelling/tenderness in calves, or a history of varicose veins.

Musculoskeletal: No joint pain, joint stiffness, muscle pain, low back pain, or history of fractures.

Psychiatric: He denies having anxiety, depressive, or psychotic symptoms. He denies having an addiction to alcohol or drug substances. No history of psychiatric admission. 

Neurologic: Negative for headache, dizziness, fainting, muscle weakness, constant mood changes, loss of sensation, or tingling sensations.

Hematologic: Negative for bruising or bleeding. No history of anemia or blood transfusion. 

Endocrine: Negative for heat/cold intolerance, excessive sweating, thinning hair, polydipsia, polyuria, or polyphagia.

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Discussion 3 Pharmacology 

1. Hypertension is high blood pressure which is an effect of high pressure in the arteries (Staessen et al.,2003). This can cause a high risk of cardiovascular disease. When it comes to the goal of drug therapy for hypertension it is to aim in reduction of cardiovascular diseases such as heart attacks or strokes (Staessen et al.,2003). Another goal is to be able to decrease organ damage that can occur to the heart, brain, lungs, and kidneys. Also, controlling individuals’ blood pressure allows in the aid to decrease chances of cardiovascular disease. Drugs that might help with these include diuretics, beta-blockers, ace inhibitors, Angiotensin II receptor blockers known as ARBs, and lastly calcium channel blockers (Staessen et al.,2003). To begin, diuretics help in lowering blood pressure by taking out water and sodium by urination. Beta-blockers work directly on the heart by lowering heart rate in individuals. This allows for less contractility and workload on the heart. Ace inhibitors causes arteries to shrink which allows the blood vessels to dilate and, in effect lowers blood pressure (Staessen et al.,2003). However, ARBs cause arteries to narrow and allows for them to remain open. Lastly, calcium channel blockers block calcium from entering the heart. By the blockage of calcium, it causes the heart rate to slow down and relaxes blood vessels (Staessen et al.,2003). Overall, all these medications contribute to lowering blood pressure. 

1. There are many different types of arrhythmias. The most common arrhythmia is known as Atrial Fibrillation. In A-fib you have irregular and fast heartbeats. Treatment for this is usually blood thinners, medications to control heart rates such as metoprolol, and surgeries such as catheter ablation and cardioversion might be needed (Tse,2016). Another is ventricular arrhythmia which is a fast heart rhythm. This can be life-threating. Treatments such as amiodarone or cardio-defibrillation. Bradycardia is a slow heart rate categorized as lower than 60 beats per minute (Tse,2016). Treatment might include medications such as atropine, epinephrine, or pacemaker insertion. Supraventricular tachycardia irregular fast heart rate categorized by 150-250 beats per minute. Treatment may include adenosine or vagal maneuver (Tse,2016). 

1. Atrial Fibrillation is irregular fast heartbeats. Patients may experience symptoms such as shortness of breath, palpitations, fatigue, and heart failure (Prystowsky et al., 2015). Treatment is based on each individual’s presentations. How long they’ve had it, the frequency and the symptoms (Prystowsky et al., 2015). To control heartbeat medications such as beta-blockers and calcium channel blockers may be ordered. In regards to the irregular rhythm antiarrhythmics such as amiodarone might be ordered (Prystowsky et al., 2015). Lastly, anticoagulants are prescribed in order to thin out the blood known as warfarin (Prystowsky et al., 2015). Overall, it all depends on the individual in severe cases catheter ablations might be performed. 

1. Anemia is when there is a decrease in the amount of red blood cells or when the number of hemoglobin decreases. There are many different types of anemia. Iron deficiency is the most common. This one occurs when there is a decrease of iron in the blood (Broadway-Duren et al.,2013). Causes can be blood loss or a lack of iron in the body (Broadway-Duren et al.,2013). Common side effects associated may be dizziness, fatigue, and brittle nails. Treatments include iron supplements (Broadway-Duren et al.,2013). Aplastic anemia occurs when the bone marrow doesn’t make enough red blood cells, platelets or white blood cells (Broadway-Duren et al.,2013). Certain auto-immune disorders can cause this. Individuals experience bruising, frequent infections, and bleeding (Broadway-Duren et al.,2013). Ways to treat this may be through blood transfusions, bone marrow transplants, or immunosuppressive therapies. Lastly, sickle cell anemia is when red blood cells are abnormally shaped (Broadway-Duren et al.,2013). Symptoms include jaundice, pain, and fatigue. This anemia can lead to organ failure (Broadway-Duren et al.,2013). Treatments include blood transfusions and pain medications (Broadway-Duren et al.,2013). 

References 

Broadway-Duren, J. B., & Klaassen, H. (2013). Anemias. Critical Care Nursing Clinics, 25(4), 411-426. 

Staessen, J. A., Wang, J., Bianchi, G., & Birkenhäger, W. H. (2003). Essential hypertension. The Lancet, 361(9369), 1629-1641. 

Tse, G. (2016). Mechanisms of cardiac arrhythmias. Journal of arrhythmia, 32(2), 75-81. 

Prystowsky, E. N., Padanilam, B. J., & Fogel, R. I. (2015). Treatment of atrial fibrillation. Jama, 314(3), 278-288.