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
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
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
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
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
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.