Nursing Question

 

Using the case study below please answer the following questions:

1. Discuss the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient you selected.

2. Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.

3. Discuss the functional anatomy and physiology of a psychiatric mental health patient. Which key concepts must a nurse know in order to assess specific functions?

Case Study  
Subjective Data
Chief Complaint
(CC)
“I came for my annual physical exam, but do not want to be a burden to my daughter.”
History of Present Illness (HPI) At-risk 86-year-old Asian male – who is physically and financially dependent on his daughter, a single mother who has little time or money for her father’s health needs.
Past Medical History (PMH) Hypertension (HTN), gastroesophageal reflux disease (GERD), b12 deficiency and chronic prostatitis
Past Surgical History (PSH) S/P cholecystectomy
Drug Hx Current Meds: Lisinopril 10mg daily, Prilosec 20mg daily, B12 injections monthly, and Cipro 100mg daily.
Allergies
Family History
Review of Systems (ROS)
General + weight loss of 25 lbs over the past year; no recent fatigue, fever, or chills.
Head, Eyes, Ears, Nose & Throat (HEENT) No changes in vision or hearing, no difficulty chewing or swallowing.
Neck No pain or injury
Respiratory
CV
GI
GU no urinary hesitancy or change in urine stream
Integument multiple bruises on his upper arms and back.
MS/Neuro + falls x 2 within the last 6 months; no syncopal episodes or dizziness
Objective Data
PE B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8
General
HEENT Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
Lungs CTA AP&L
Card S1S2 without rub or gallop
Abd benign, normoactive bowel sounds x 4
GU
Ext no cyanosis, clubbing or edema
Integument multiple bruises in different stages of healing – on his upper arms and back.
MS
Neuro No obvious deformities, CN grossly intact II-XII

Post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

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