Client initials: W. F. | ? Male X ? Female Age 75| Religion: Catholic| Allergies| Past Medical HistoryFamily History Genogram of three generations| Medications| No Known Allergies| Hypertension and Glaucoma| Metronidazole (Flagyl) 500mg by mouth every eight hours. Lisinopril (Zestril) 20mg by mouth once a day. Timolol (Timoptic) 0. 5% one drop to both eyes twice a day. | Pattern| Problem| Assessment| Nursing Diagnosis| Prioritization| Health Perception/Health Management| ? YES? NO| Subjective: “My health is usually good, I rarely have a problem”. Denies use of alcohol or cigarettes.
Patient states he lives at home with his wife. Patient also states he tries to stay active and to do what the doctors tells him. Objective: Patient is up to date on immunizations. He is compliant with the healthcare team. Call bell is within reach and ID bracelet is on his right wrist. | None| | Nutrition/Metabolic| ? YES? NO| Subjective: Patient states “My wife and I still go shopping”. He also states his wife does most of the cooking. Patient denies any weight loss. Patient states he wears dentures. Objective: Height 5ft 8in, weight 165. Mucus membranes are wet, pink, and intact. Patient’s diet is house regular.
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Patient’s appetite is good, eats well. Temperature (oral) 98. 4, skin is warm, dry, and intact. WBC 14. 4, HGB 11. 3, HCT 33. 7| Risk for fluid volume deficit related to losses secondary to diarrhea as evidenced by loose stools. | 1| Elimination | ? YES? NO| Subjective: Patient states he has a bowel movement once a day. Patient states “I started to have terrible diarrhea and I spotted some blood in the toilet”. Patient states he has no problems urinating. Objective: Patient is out of bed, in chair, Bowel sounds are hyperactive in all four quadrants. Abdomen is soft and mildly tender. Patient had three large loose bowel movements today. Diarrhea related to inflammation secondary to acute colitis. | 2| Activity/Exercise| ? YES? NO| Subjective: Patient states “I still try to do things around the house; I just have to take small breaks to rest”. Patient states he generally feels well rested and energetic enough to complete daily activities. Objective: Respirations 16 equal and unlabored, blood pressure 150/90, pulse 74, lung sounds clear. Patient observed getting up and around without signs of shortness of breath, Patient dressing himself independently without difficulty. Full range of motion observed. | None| | Sleep/Rest| ? YES?
NO| Subjective: Patient states “I usually get at least six hours of sleep at night”. Objective: Patient observed awake, alert and active. Patient refuses to lay in bed during the day. | None| | Cognitive/Perceptual| ? YES? NO| Subjective: Patient states “my hearing is starting to go and my eyesight is fading, and I can’t taste things the way I used to”. Patient states “I have a hearing aid and I wear glasses”. Objective: Patient is alert and oriented X 3 (person, place and time). Speech is clear and appropriate. Hearing aid and glasses are visible on patient. Pupils are equal, round and reactive to light. Disturbed sensory perception related to misinterpretations secondary to sensory organ alterations as evidenced by use of hearing aid and glasses. | 3| Self Perception/Self Concept| ? YES? NO| Subjective: Patient states ” I live a good life”, “Health issues sometimes scare me but I always pull through”. Objective: Patient appears calm, pleasant, and cooperative. No visible anxiety. Appears to have a strong self-concept. | None| | Coping/Stress| ? YES? NO| Subjective: Patient states “I usually feel relaxed, and when I have a problem I work through it”. Objective: Patient does not appear in any distress. Patient is calm and collected.
Patient’s wife is observed in the room with the patient. | None| | Role/Relationship| ? YES? NO| Subjective: Patient states “I live at home with my wife”. Patient states “I have a son and daughter, and two grandkids”. Objective: Family dynamics appear pleasant. | None| | Sexual/Reproductive| ? YES? NO| Subjective: Patient states “I have a son and a daughter”. Objective: N/A| None| | Values /Belief| ? YES? NO| Subjective: Patient states “my religion is catholic; we try to make it to mass once a week”. Objective: Patient took communion as an inpatient. Rosary beads observed at patient’s bedside. | None| |