Case study: Subjective Data: Chief Complaint: “I

Case study: Subjective Data: Chief Complaint: “I came for my annual physical exam, but do not want to be a burden to my daughter.” History of Present Illness: 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. 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 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 HEENT: Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. Lungs: CTA AP&L Cardiovascular: S1S2 without rub or gallop Abdomen: benign, normoactive bowel sounds x 4 Extremities: no cyanosis, clubbing or edema Integumentary: multiple bruises in different stages of healing – on his upper arms and back. Neuro: No obvious deformities, CN grossly intact II-XII 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?

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