iHuman Management Plan Template for NURS 6550 and NURS 6560

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iHuman Management Plan Template for NURS 6550 and NURS 6560: 17yo Female 5’4”, 168lbs CC: Fatigue, started about two months ago, lot of pressure because of senior year, nothing makes it better,... wakes up tired, doesn’t matter how much sleep I get, gained 25-30 pounds since last year, not trying to; stretch marks Assessment: Height—5’4” Weight—168lbs BMI—28.8 Temp 98.6 Pulse 68 Respirations 15 BP 110/78 spO2 99% RA General appearance—Young female in no apparent distress, tearful, irritable HEENT—PERRLA, EOMI. Normocephalic. Trachea midline. No lymph nodes noted. Lungs—Breathing unlabored, regular rate. Lungs CTA bilaterally, anterior and posterior. Heart—Heart sounds s1/s2, regular rate and rhythm. Pulses regular. Abdomen—Skin intact, no lesions noted. Normoactive BSx4. No pain or rebound tenderness noted. GU—Breast exam WNL. Skin, hair, nails—acne, acanthosis nigricans noted, skin is warm and dry Psych—Tearful, anxious, irritable, reluctant to make eye contact. Denies any suicidal/homicidal ideations Primary Diagnosis: Depressive disorde [Show More]

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