| Case 1 | |||
| Subjective Data | |||
| Chief Complaint (CC) |
“I came for my annual physical exam, but do not want to be a burden to my daughter.” | ||
| History of Present Illness (HPI) | At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs. | ||
| PMH | Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis | ||
| PSH | S/P cholecystectomy | ||
| Drug Hx | Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily. | ||
| Allergies | |||
| Family Hx | |||
| Review of Systems (ROS) | |||
| General | + weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills. | ||
| Head, Eyes, Ears, Nose & Throat (HEENT) | No changes in vision or hearing, no difficulty chewing or swallowing. | ||
| Neck | No pain or injury | ||
| Respiratory | |||
| CV | |||
| GI | |||
| GU | no urinary hesitancy or change in urine stream | ||
| Integument | multiple bruises on his upper arms and back. | ||
| MS/Neuro | + falls x 2 within the last 6 months; no syncopal episodes or dizziness | ||
| Objective Data | |||
| PE | B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8 | ||
| General | |||
| HEENT | Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. | ||
| Lungs | CTA AP&L | ||
| Card | S1S2 without rub or gallop | ||
| Abd | benign, normoactive bowel sounds x 4 | ||
| GU | |||
| Ext | no cyanosis, clubbing or edema | ||
| Integument | multiple bruises in different stages of healing – on his upper arms and back. | ||
| MS | |||
| Neuro | No obvious deformities, CN grossly intact II-XII | ||
Answer the following questions:
- Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
- Utilizing the five assessment domains, which ones would you utilize on your patients in conducting a comprehensive nutritional assessment.
- Discuss the functional anatomy and physiology of a psychiatric mental health patient. Which key concepts must a nurse know in order to assess specific functions?
Submission Instructions:
- Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
