Mrs. Jones, an 80-year-old Caucasian female adult presents to her family physician’s office with complaint of increased heart burn. She has been using Mylanta to hold it in check, but recently, it has not let up. “I try to take care of myself.
When I couldn’t stop the heart burn from coming back, I made an appointment with you folks.” The nurse has Mrs. Jones get on the scale and also does a height measurement. The client is questioning the correctness of the height measurement.
The nurse has her medical folder with prior history and medication information and reviews it with the client. The only new findings are the heart burn and height.
Objective Data
Vital signs, weight, and height are checked for the current visit.
HR-80, BP-122/84, RR-18, Temp-98.4, Weight-145 lbs., Height-5ft 4.5in.
History & Medications on File
History:
-non-smoker
-A fall at home two years ago resulted in a fracture of the right radius and ulna. Casting was 4.5required for three months.
-Chronic arthritis: Managed with Advil. Severe bouts of pain (x3 in last 10 years) has required an injection of a glucocorticoid.
-Breast cancer 20 years prior. Treated successfully with chemotherapy and radiation.
-Occasional sinus infections. Managed with Sudafed.
-Previous Vitals: HR-78, BP-119/80, RR-18, Temp-98.4, Weight-142 lbs., Height-5ft, 6in.
Meds:
-Multiple vitamin
-OTC: Advil, Mylanta, Sudafed
Investigational Questions / Statements:
1. Physiology – Discuss conditions that contribute to osteoporosis.
2. Assessment – Discuss test(s) that screen for osteoporosis.
3. Diagnosis – Provide one (1) nursing diagnosis and one (1) collaborative diagnosis. The
nursing diagnosis should include ‘related to’ factors and ‘as evidenced by’ for support.
You may use bullet points to list the diagnosis.
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