Charting Day 1

Subjective:

 History if Meningitis

o Reports Meningitis was diagnosed December 2019.

o Patient was cleared of diagnosis with aggressive treatment with steroids and
antibiotics.
o Patient reports she experiences mild-moderate headaches 3 times a week and
utilizes Tylenol extra strength and Norco.

 Patient fractures right elbow during soccer game July 2018.

 Patient takes the following home medications
o Birth control- Xulane Patch Daily
o Tylenol extra strength 325 mg every 6 hours as needed for mild pain (1-4).
o Dexamethasone 0.15mg/kg Daily
o Vitamins: Multi-vitamin
o Norco 5mg/325mg every 6-hours as needed for breakthrough pain (5-9).
 Patient states her head feels swollen
 Patient reports elbow fracture is completely healed and has no problems with
movement.
 Patient reports no tenderness when opening jaw.
 Patient reports having no difficulties or pain with range of motion neck exercise.
 Patient reports mild pain 4/10 associated with canker sore in mouth and difficulty
eating food.

Objective:

 Skin color normal with pink rosy cheeks.

 Skin turgor normal, no tenting present

 Skin texture is smooth and soft
 Skin dry, warm, pink, and intact.
 Mild edema present in occipital lobe and parietal lobe area.
 No edema in upper and lower extremities.
 Capillary refill less than 3 seconds X4 extremities.
 Nails are convex shape with gel nail polish.
 Hair is evenly distributed, fine but high quantity present.
 No lesions on scalp present.
 4cm X 3cm scab and bruising on lumbar region between L3-L4 from lumbar puncture.
o Slight redness around scab
 Linear scar located on right anterior of elbow.
  Small numerous freckles located on upper extremities within normal limits with
asymmetry, clean border, brown color, less than 6mm in diameter, and not elevation
notes.
 Facial features intact with full movement. Facial symmetry when smiling and raising
eyebrows.
 Oral cavity pink and moist with tonsils present within normal size limit.
 Small canker sore noted in left check of oral cavity.
 Conjunctiva white with no redness noted.
 Bilateral pupils are equal round and reactive to light. PERRLA intact.
 Six cardinal movements within normal limits and patient able to follow commands.
 Nasal passage is patent with no discharge or deviated septum noted.
 Bilateral ears within normal limits with auricle shape, symmetry, color, and position
 TMJ non-tender and clicking not present with movement of jaw.
 Neck has full range of motion; trachea positioned midline, and no goiters or nodules
noted.
 Lymph nodes palpated and tenderness and swollen not present in auricular nodes,
submandibular, submental, anterior and posterior cervical chains, and supraclavicular
nodes.

Assessment

 Patient is a risk for infection due to steroid use causing immunosuppression.

 Patient at risk for seizure activity due to history of meningitis and headaches.
 Patient at risk of impaired liver function due to Tylenol and Norco medications used
for pain.
 Patient at risk for mouth ulcer due to canker sore present.

Plan

 Teach patient about steroid medication use, weaning off medication, and infection
precautions.
 Teach patient about Tylenol maximum daily dose. Not to exceed 3 grams daily from all
APAP sources. Educate patient on risk of liver function impairment due to increased
medication usage.
 Teach patient about signs of infections and what to report to doctor.
 Teach patient to take rest periods when feeling tired, not overexert self, and conserve
energy.
 Educate on the importance of sunscreen when in direct sunlight due to increased
freckles and fair skin.
 Educate on mouth rinses, and topical medications to decreased inflammation and
reduce pain.
 Educate patient to observe oral cavity daily and to report any abnormal findings such
as increased redness, swollenness, white patches, or difficulty swallowing to doctor.