Question

J.P .is a 75-year-old retired factory worker who is being seen in the home setting for a yearly health assessment provided by his insurance company. ubjective Data No complaints at this time Enrolled in Silver Sneakers Eats out much of the time Widowed Has one daughter who lives in another state Retired automotive parts factory worker Drives to and from activities Objective Data Vital signs: T 37 P 80 R 18 BP 140/68 Weight: 200 HT: 5 feet, 6 inches Question:--1. How should the nurse proceed with the interview portion of the assessment? 2. What are the components necessary to complete the interview? 3. Develop a problem list for subjective findings,4. Develop a problem list for objective findings 5.What teaching should the nurse consider from the problems list? 6.What might be included in the plan of care for this patient?

Answer 1

Answer:

1. The should start from assessment of lungs and heart sounds. After that, ask the for any regular medication that he is taking. Ask the patient for his previous blood pressure value and enquire him for vigorous activities or exercise for last week. Collect the family history and dietary patterns of the patient.

2. Patient interview consists of three components. Introduction, discussion and summary. In the introductory phase the nurse will introduce herself and about her nursing role. In the discussion phase the nurse will ask questions about the medical history and various aspects of his health of the patient.The nurse actively listen to the patient's reply. In the end phase the nurse summarize the main points and emphasis on plan of care.

3. Subjective data

* No complaint presently

*Eats out much of the time

*Enrolled in silver sneakers

*Widower

*One daughter lives in another state

*Retired from automotive parts factory

*Drives to and from activities

4. Objective data

*Vital signs - Temperature: 37 , pulse : 80

Respiratory rate : 18, Blood pressure : 140/68

* Weight- 200 , Height- 5 feet,6 inches