Client initials: W.F.
| Male X Female Age 75
| Religion: Catholic
| Past Medical HistoryFamily History Genogram of three generations
| 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.
| Nursing Diagnosis
| 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.
| 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. 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.
| 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.
Please join StudyMode to read the full document