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¶ … patient's general health been? - The Patient, Mr. Jones has generally been good but with frequent cases of heart complications. The situation has been deteriorating over time.
Any colds in past years that required absences from work?-None
Most important things you do to keep healthy? -- regular jogging exercise and being a vegetarian
Accidents (home, work, driving)?-Twice when the patient experienced a heart attack
In past, has it been easy to find ways to follow suggestions from physicians or the nurses? Yes
F. If appropriate: what do you think caused the illness? I believe the illness was caused by the kind of lifestyle that I had (smoking and eating high cholesterol meals while also leading a sedentary life)
g. If necessary: outline the things important to you in your health care? How can we be most helpful? I require hypertensives and advice on how to live a healthy life
Examination -- the general health appearance is frail. There is a need for immediate therapy
NUTRITIONAL-METABOLIC PATTERN
1. History
a. Typical daily food intake?-The typical daily food intake includes bread and coffee, milk, meat chops, broccoli, steak, vegetables such as cabbages and tea.
b. Typical...
Weight loss or gain? The patient has over the years been gaining wait owing to a sedentary lifestyle
d. Appetite? The appetite for this patient has been incredible.
e. Food or eating problems. None f. Heal well or poorly? Heals well granny Skin problems: None
h. Dental problems? Has had 2 premolars removed via root canal operation.
2. Examination
a. Skin: Always moist
b. Oral mucous membranes: Normal color, always moist and healthy.
c. Teeth: The teeth are generally white in color with some discoloration of the molars .two premolars had previously been extracted due to cavity and infection of surrounding tissue.
d. Actual weight -- the patient weighs 104 Kilograms and is 179 cm tall.
e. Temperature -- the temperate is 37 degrees Celsius
f. Intravenous feeding -- none whatsoever
ELIMINATION PATTERN
1. History
a. Bowel elimination pattern? No elimination problems. No retention problems.
b. Urinary elimination pattern? The patient has an increased rate of urinations.
c. Excessive perspiration? Yes with…
References
Gordon, M. (2000). Manual of nursing diagnosis: 1995- 1996. St. Louis: Mosby.
Gordon, M. (1994). Nursing diagnosis: Process and application (3rd ed.). St. Louis: Mosby;
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