Judy

SKIN

HAIR

NAILS

URINARY

MEDS

Atenolol
For high blood pressure #
Could be contributing to constipation

Baby Aspirin - Low Dose
Blood thinner for high BP and cholesterol

Vitamin D
Supplement for greater absorption of calcium

Calcium
To supplement for the loss of calcium from omeprazole

Biotin
For hair, skin and nails # #

B12

Fish Oil

Simvastatin
High cholesterol
Takes at night
Could be contributing to constipation #

Omeprazole
Prevention of Barret's Esophagus
Could be contributing to frequent urination #

Pearls
Constipation

Interactions

Calcium and Atenolol
-Calcium decreases the effects of atenolol

Aspirin and Atenolol
-Aspirin decreases the effects of atenolol by antagonism
-NSAIDS decrease prostaglandin synthesis
-Both increase serum potassium (could be bad if too high)

Omeprazole and B12
-Omeprazole decrease the levels of B12 by inhibition of GI absorption

Aspirin and B12
-Aspirin decreases the levels of B12 by inhibition of GI absorption

Pt. states that she has not noticed any SE from medications # #

She is taking all medication in the AM
Only taking simvastatin at night d/t increased cholesterol synthesis

Has 3 children: all births went with no complications
Lost one child at 7 months pregnant
-Born premature and was not in a hospital

No surgeries for any disorders
-Had a hysterectomy
-Gallbladder removal

No vaginal infection
No urinary tract infections
No pain, burning, or discomfort when urinating

Chronic Illnesses
-High blood pressure
-High cholesterol
-Chronic constipation
---takes pearls to help and laxatives to go # # #
-Pre Diabetic #

Drinks about 3 bottles of water a day
3 cups of coffee in the AM
Diet soda (few per week)
Alcohol is a social drink # #

Leaks urine every once in a while
Typically happens when she holds it too long
Wears a light pad during the day for potential accidents
Hard to hold after holding it for a long time after first sensation
Does not leak w/ a cough, sneeze, or laugh
Wakes up 2-3 times on average during the night to use the bathroom
--Is unsure if it's due to needing to use the bathroom or if she woke up for a different reason
Some residual after using the bathroom, not a lot
Does not need to exert pressure to feel as though she emptied her bladder # #

NUTRITION

Oral Care
Brushes teeth in AM and PM
-Sometimes TID if home
Listerine mouthwash w/ each brush
Flosses every few days

No dyshagia

Meals are TID w/ a snack in between
Getting better about meal times and eating healthier # #

No specific cultural or spiritual beliefs

Socioeconomic Factors
Retired
Married
Financially stable
Can afford all bills and adequate food
Travels often with husband
Environmental Factors
Lives in a retirement community
Rural
Drives on her own
Easy access to shopping and PCP
Low pollution #

Lifestyle
Loves to travel
Gambles often w/ husband
-within means
Relaxed
Many social activities
Weight Watchers

Mini Nutritional Assessment
Score of 13/14
Normal Nutritional Status

Strong and well-manicured
Hands and toes are painted with nail polish
Feet are dry and warm (pre diabetic)

Cap refill <3 sec.

Nails are stronger than they used to be
Has noticed a better change in nails since taking biotin

Intact, no lesions
Warm and dry
Color: congruent w/ ethnicity
-No abnormal discolorations
Skin is dry but not flaky
-Lotion is used every day
No s/sx of dehydration
-No skin tenting
-Mucous membranes are pink and moist

Has a bunion on her right foot by her big toe
Has noticed that her skin has changed
-More liver spots
-Skin is more dry
--Sometimes itchy d/t the dryness
Wearing shoes is not uncomfortable
No scars noted

Products
Dove body wash
Shampoo and conditioner for color treated hair
Lotion: Gold Bond - rough and bumpy skin
Face lotion includes SPF
Wears sunscreen when in the sun for long periods of time # # #

Hair is in good condition
Hair is cut by daughter typically once every two months
Hair is colored
Uses color treated shampoo and conditioner to maintain healthy hair
Gets a perm every few months to maintain volume

Hair is strong
No split ends visible
No graying visible
-colored hair

Nursing Diagnosis
Functional urinary incontinence r/t environmental barriers to voiding AEB inability to make it to the bathroom in time and slight leaking into mini pad.

Pt. will eliminate or overcome the environmental barriers to using the bathroom by the end of this week.
-Pt. states that she waits to long at times to go tot he bathroom

Pt. will reduce incontinent episodes by the end of this week.

Nursing Diagnosis
Constipation r/t unable to pass stool AEB not defecating for 5-6 days at a time, takes laxative to go, and takes pearls to initiate regulation.

Nursing Diagnosis
Risk for impaired skin integrity: scratching, itching r/t dry and itchy skin.