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Patient 81 year old female By Cori Biersteker (Respiratory (SUBJECTIVE …
Patient
81 year old female
By Cori Biersteker
Respiratory
SUBJECTIVE
Patient reports she has no history, or family history, of asthma, COPD, TB, or chronic pneumonia
Patient reports she has had no exposure to coal, asbestos, or molds.
Patient states she used to work at "AC Delco" and "I don't know what I was exposed to there."
Patient states she has been exposed to a moderate amount of second hand smoke "but not recently"
Patient denies any SOB or trouble breathing.
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INTERVENTIONS
1) Patient will ask all guests to smoke outside of her home every time they visit.
2) Patient will avoid spending any time in smoke filled rooms every time she is near one when she is outside her home.
3) Patient will take a shower, wash hair, and launder clothing if she has been exposed to any second hand smoke every time is happens.
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OBJECTIVE
Patient does not appear to be using any accessory muscles to breathe.
Patients lungs sound clear.
Patient does not appear to be SOB when walking short distances.
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WELLNESS DIAGNOSIS
Readiness to learn about the effects of smoking on health AEB exposure to secondhand smoke
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NEGATIVE CONSEQUENCES
If patient does not limit her time around second hand smoke she is putting herself as risk for asthma, pneumonia, lung infections, and even cancer,
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GOALS
Patient will do what she can to limit any exposure to second hand smoke to help maintain her lung function.
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Cardiac
OBJECTIVE
Female
81 years old
Pulse 71
BP 102/62
Weight 135 lbs
Height 5' 0"
BMI 26.4
RR 16
No abnormal heart sounds present
Radial pulses +2 bilateral
No neck vein distention present
No edema present
Apical pulse is congruent with radial pulse
Unable to complete CAD risk assessment due to unknown cholesterol lab values.
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WELLNESS DIAGNOSIS
Readiness for enhanced knowledge R/T interest in developing heart healthy dietary habits AEB current diet high in salt
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INTERVENTIONS
1) Patient will consume less than 1,500 mg of sodium each day.
2) Patient will consume 4-5 servings of vegetables each day.
3) Patient will eat 6 servings or less of lean meats, poultry, or fish per day.
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NEGATIVE CONSEQUENCES
If patient does not adhere to the DASH diet it will put her at risk for more heart related diseases, edema, stroke, diabetes, and obesity.
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SUBJECTIVE
Denies chest pain or tightening
Denies dyspnea and shortness of breath,
Patient states "I only felt dizzy before they changed my pacemaker battery"
Patient states "My heart feels fine"
Patient denies history of heart murmur
Patient states "I need a nap during the day"
Patient states "My digestion is fine I think. I just burp a lot."
Patient states her feet and ankles get swollen "Only sometimes."
Patient denies waking during the night due to difficulty breathing or discomfort
Patient denies pain in her upper back or shoulders
Patient states she had a pacemaker placed in September of 2008
Patient states she has history of hypertension, CHF, high cholesterol.
Patient denies CAD, atherosclerosis, aortic stenosis, arrhythmias, cardiomyopathy, QT syndromes, or clots.
Patient denies history of smoking or drinking.
Patient states she takes "Just one baby aspirin a day"
Patient states "I don't know my normal blood pressure but it's usually good because of my medicine"
Patient states she does not have an exercise regimen because she's "too old for that"
Patient states she "Tries to eat right but I eat too much salt and my doctor doesn't like that"
Patient states she's under "a normal amount of stress right now" and copes by "sleeping, reading, and talking on the phone"
Patient states she doesn't know any current lab values, including cholesterol levels.
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GOAL
To adhere to DASH diet's daily recommendations to maintain low blood pressure and heart healthy standard as set by her physician.
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Health Literacy
WELLNESS DIAGNOSIS
Readiness for enhanced learning AEB mismanagement of medications
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OBJECTIVE
Patient appeared to be able to explain the majority of medications.
Patient appeared to be able to explain most of her diagnosis's.
Patient appeared to know where to access appropriate information when she had questions.
Patient had an organized list of doctors and nurses with phone numbers.
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NEGATIVE CONSEQUENCES
If patient continues to take supplements that are unknown to her doctor she could be putting herself at serious risk for drug to drug interactions and complications with her current diagnosis.
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INTERVENTIONS
1) Patient will call her doctor/nurse and report to them what additional supplements she is taking when they open Monday morning.
2) Patient will discuss with her doctor about taking additional medications/supplements before she adds them to her medication regimen.
3) Patient will confirm with her pharmacist what medicine/supplements are listed in her chart after she speaks to her doctor on Monday morning.
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SUBJECTIVE
Patient states she is retired and does not volunteer "anymore"
Patient states she has healthcare coverage.
Patient states she is current on both her flu and pneumococcal pneumonia vaccine
Patient states she has allergies to Gabapentin, Baclofen, and Fluconazole.
Patient states she has a history of high cholesterol, CHF, hypertension, arthritis, anxiety, and depression.
Patient states "I just take what my doctor tells me to, I know what most of them are for"
Patient states "I ordered some supplements off the TV too. My doctor doesn't know that though."
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GOAL
Patient will communicate with her healthcare team to make sure her medications and supplements are in order and do not pose any risk to her health.
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