Sexuality-Reproductive Pattern Paper
Sexuality-Reproductive Pattern: Client not sexually active for about 2 years
Pattern of Elimination: Constipation, takes Colace and eats salad to help with bowel movement
Pattern of Activity and Exercise: Client is active, goes to the gym at least 3x weekly before her back injury. Still goes to work on modified duties.
Pattern of Sleep and Rest: Client does not rest during the day and gets about 6 hours of sleep at night.
Pattern of Self-Perception and Self-Concept: Client has gained a lot of weight of late and was doing well with weight control by going to the gym but now with her back hurting, not sure when to go back. Client is very concern and worried about her situation; Client reassures herself that she’s doing her best to help her children but must be healthy for this to continue.
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Surgical history includes appendectomy, hysterectomy, right breast biopsy, C-Section 2006 and 2008. Patient currently takes orally Benicar/HCTZ 40/25mg daily, Metformin 500mg BID, Atorvastatin 20mg daily, Motrin 600mg Q6 hours as needed for pain, Flexeril 10mg BID and Colace 100mg daily.
Mother has DM and Father died of CVA.
Assessment (assessment of health state or problems, nursing diagnosis):
Client is a bit anxious with facial grimacing when moving from a sitting to standing position, BP elevated at 160/90, able to stand or sit straight but musculoskeletal assessment of the lower extremities reveals difficulties with mobility, experiences great pain and discomfort when attempting to looking down, bend, sit for a long time or reach down. There was no problem with upper extremities.
Client is having pain related to lower back injury as evidenced by compliant of pain level of 9/10
Risk for fall or injury related to pain and weakness of right lower extremity
Constipation related to inadequate diet as evidenced no irregular bowel movement.
Ineffective coping related to stress as evidenced by
Pattern of Elimination: Constipation, takes Colace and eats salad to help with bowel movement
Pattern of Activity and Exercise: Client is active, goes to the gym at least 3x weekly before her back injury. Still goes to work on modified duties.
Pattern of Sleep and Rest: Client does not rest during the day and gets about 6 hours of sleep at night.
Pattern of Self-Perception and Self-Concept: Client has gained a lot of weight of late and was doing well with weight control by going to the gym but now with her back hurting, not sure when to go back. Client is very concern and worried about her situation; Client reassures herself that she’s doing her best to help her children but must be healthy for this to continue.
Summarize …show more content…
Surgical history includes appendectomy, hysterectomy, right breast biopsy, C-Section 2006 and 2008. Patient currently takes orally Benicar/HCTZ 40/25mg daily, Metformin 500mg BID, Atorvastatin 20mg daily, Motrin 600mg Q6 hours as needed for pain, Flexeril 10mg BID and Colace 100mg daily.
Mother has DM and Father died of CVA.
Assessment (assessment of health state or problems, nursing diagnosis):
Client is a bit anxious with facial grimacing when moving from a sitting to standing position, BP elevated at 160/90, able to stand or sit straight but musculoskeletal assessment of the lower extremities reveals difficulties with mobility, experiences great pain and discomfort when attempting to looking down, bend, sit for a long time or reach down. There was no problem with upper extremities.
Client is having pain related to lower back injury as evidenced by compliant of pain level of 9/10
Risk for fall or injury related to pain and weakness of right lower extremity
Constipation related to inadequate diet as evidenced no irregular bowel movement.
Ineffective coping related to stress as evidenced by