Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
Using the case study below please answer the following questions:
- Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.
- Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
- 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?
| Case Study | |||
| 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. | ||
| Past Medical History (PMH) | Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis | ||
| Past Surgical History (PSH) | S/P cholecystectomy | ||
| Drug Hx | Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily. | ||
| Allergies | |||
| Family History | |||
| 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 |
Post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
Requirements: 500 words | .doc file
Nursing
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