NU120 Case Study
NURSING PROCESS FOR CLINICAL REASONING
FUNCTIONAL HEALTH PATTERNS AND NURSING DIAGNOSIS
C;lient; Mrs. Wisdom
Address: Senior housing, small apartment, urban location
Elder Day Care located in her building
Contact person: Daughter who lives in nearby suburb, works from home
Demographics: Age: 86, Gender: Female, Race: Caucasian, Culture: Italian-
American (language, food, conversational content, neighborhood),
income:social security and small pension
Education: Primary school in Italy. Emigrated age 18 to marry.
Occupation Seamstress and alterations person for bridal shop 18 - 70.
Retired since age 70.
Religion: Roman Catholic, daily mass at church four blocks from current
housing till age 80.
Source of history: Client
Reliability of source: Reliable - data verified with daughter and medical record
Reason for contact: Assessment by advanced practice gerontological nurse for
potential admission to adult day care canter in building.
Health Perception-Health Management Functional Health Pattern
Present Health Status:
Reports dizziness on arising in morning. Increased napping during day. "Feels good". Doing own home care and cooking till now. Shops for food on her own in neighborhood store two blocks away. Defines health as feeling well enough to care for herself and be no bother to anybody.
Goes to doctor only if she feels very ill, for example a headache or trouble breathing, and when her prescribed medications run low. In the past she experienced swelling and shortness of breath that did not go away when she restricted fluids. Her belt and shoes were tight and she would be short of breath climbing stairs or a hill. Finally, she went to a doctor and now takes a diuretic and an anti-hypertensive medication. The symptoms have not recurred. Mrs. Wisdom has complete dentures. - no contact with dentist since getting them. She saw an eye doctor two years ago and plans to revisit soon because she notices that glare bothers her outside. Mrs. Wisdom says she does not have any information on Health Proxy - Advance Directives. She does not do self breast exam and has not had a mammogram. She never smoked and uses alcohol only in the form of red wine with a meal occasionally. She takes a bulk laxative daily to assure bowel regularity.
Mother (died 90 - heart gave out) Father (died 40 - accident)
Siblings : 3 sisters lived in same area, younger, all dean from strokes( brain
Events), 1 brother alive and well in Italy, age 75.
Husband - died at age 35, cancer
Three children, all girls, alive and well, live nearby, likes her sons-in law even
though two are not Italian. Five grandchildren. Sees family at least once a week, uses phone for contact.
Nutritional-Metabolic Functional Health Pattern:
Good appetite, likes variety of foods
Prepares meals and eats on a regular schedule, often eats food made by daughters for weekly family gatherings:
Breakfast: toast, coffee
Midmorning: fruit or soft nutmeats
Lunch: bread and soup she makes from leftover meat and vegetable
Supper: pasta, vegetables, chicken or beef, sometimes fish, sometimes wine
Height 60 in Weight 159
Temperature 97.4 axillary
Skin clear, intact, lentigo senilis/solar on hands, skin tags on neck and chest
Sternal skin turgor good.
Elimination Functional Health Pattern
Usually has a bowel movement sometime in morning since taking bulk laxative
And "feels good if regular". Abdomen soft, no distention, bowel sounds all
Voids frequently, including three times awakened from sleep since taking
diuretic. Sometimes "pees self" if she laughs or coughs suddenly.
Activity-Exercise Functional Health Pattern
Usually walks within one to two blocks from housing or in courtyard of
residence - no pain in chest or legs, no problem breathing since prescription used.
If she walks further, she tends to have pain in hips and knees and has to rest to get
rid of the pain. Cannot climb usual bus step but daughter helps her reserve special bus for appointments or gives her a ride. Has a chair in shower and can bathe self with shower spray.
Dresses self but has to select clothes in store or catalog that are easy to put on
and fasten - has pull on pants and skirt, velcro fastened shoes. Daughter takes her
to hairdresser weekly for shampoo and set. Manages toileting by self. Toilet is
near her sleeping area.
ADL's (Katz) IADL's (Lawson)
Feeding Use of telephone
Toileting Food preparation
Bed mobility Transportation
Does not know her blood pressure but knows it was high when doctor prescribed
Pills. BP = 160/90 both arms, regular cuff. Apical and radial P 88, regular. R 18 sitting.
Walked briskly four times back and forth small living room approximally 40 feet
- p, bp, r to baseline in eight minutes. Posturals within ten points, no dizziness.
Does not report orthopnea, no recent dyspnea or SOB. Lung sounds clear.
Peripheral pulses palpable. Finger and toe capillary refill good.
Cardiac Risk Factors
Sedentary life style
Posture straight, no kyphosis or scoliosis, reports she felt shorter recently when
walking with daughter. Finger joints enlarged but not painful or misaligned.
Can move all joints slowly but reports stiffness in morning. Equal hand grasp and leg raising. Gait broad based, hand swing coordinated. Writes name slowly and legibl y. Right handed.
Sleep-Rest Functional Health Pattern
Awakened times three to void. Sleep onset easy, after 10 P.M. news, awakens
6 A.M., same as when she worked. Does not feel well rested.
Cognitive-Perceptual Functional Health Pattern
Asks nurse to speak more slowly, responds to usual voice level when pace
slowed. Reports she is bothered by background noise in crowds or outdoors.
Can read larger print of newspaper - all headings. Left eye lens clouded, wears
hat or visor when near window or outdoors. Wears bifocal glasses since
Can figure out new needlework patterns for friends who sew and knit(Horn &
Cattell's fluid intelligence). Does quilting. Counts in Italian(Horn & Cattell's
Wears extra clothes because sensitive to cold - likes nice fabrics and colors,
touch for sewing good, slightly less sense of smell for food ingredients.
Does not seek health information, doctor takes care of her when needed but says she learns lots of new things from TV - sometimes shocking. She was always too
busy to be a reader.
Says she is a good problem solver and talks out decisions with family or friends
(Fluid intelligence, Riegel's dialectic) Consults her priest about important changes. Thinks about meaning of life and past experiences (Schaie's cognitive integration, Butler's life review, reminiscence and Erikson's identity integrity)
Remembers grandchildren's as well as children's birthdays.
Only minor aches and pains, stiffness until this dizziness - never dwells on small
physical problems (Peck body preoccupation versus body transcendence)
Mini-mental exam (Folstein)demonstrated good orientation, memory , attention. Reflexes slightly sluggish. Eye acuity 20-50 corrected and fields intact. Reads headline without head motion. Can hear whisper from 12 inches - bilaterally. Ear canals demonstrate some accumulation of cerumen. Sensation intact for heat cold, light, touch.
Self Perception-Self Esteem Functional Health Pattern
Proud of herself for surviving loneliness from husband's early death and for
raising "good" daughters. Proud of work that she did - for the bridal shop. Happy now that she can live on her own and not bother family too much. Rates self esteem at 7 on 1 - 10 scale "does not want to be too proud" Thought she wanted to be a hairdresser but then learned about sewing opportunities and tried it, liked it. ( Marcia identity status/Erikson: work/vocational) Never questioned anything about her religion. Worries about attitudes of people today. "Follow the rules and you will be happier" (Marcia identity status/Erikson: values)
1. Expressed liking for friends and family
2. Expresses her beliefs
3. Plans on a daily basis, not too far ahead
4. Skilled cook, homemaker, seamstress -- completes projects
5. Does not remember being a teenager - learned about sexualtiy from
cousin and husband, childbearing from friends
6. Was married to a "good" man, still misses him
7. Raised three daughters, sewed their clothes and taught them to sew
and cook, helps neighbors with needlework
8. "Good, full life", at peace with self and God but in no rush to die, likes to
recall good times, teary over losses.
Role Relationship Functional Health Pattern
Frequent visits and calls to and from family members, friendly with other residents of senior housing by notices that being confined to her unit would be lonely.
Liked fulfilling her several life roles, missed work contacts and took a long time to adjust to retirement but did continue contact by phone (Neugarten) when all grew too old to go out together. Retirement did give her time to take up quilting that she enjoys.
Sexual-Reproductive Functional Health Pattern
Does not remember age of menarche but recalls preparation by friends - says her grandchildren have sex education in school - wonders if this is good for them. Menopause in her "fifties" - no special concerns, glad to through with care during periods. Hates MD exams and tries to delay them, no mammogram. Had three full term pregnancies and vaginal delivery in hospital. Little recall. Never had good information about this area of life. Does not think church approves of thinking or talking about it. Thinks too much information if given on TV today, but admits she has learned things she wishes she knew earlier in life.
Coping-Stress Tolerance Functional Health Pattern
First resort when she is troubled is saying prayers, her rosary. She may cry in
Frustration and then can talk to family or friends or priest. Sometimes they make
her contact doctor. Most problems now relate to health and independence. Feels
most problems can be solved - has survived great losses and remembers pain and
recovery (stress hardiness)
Value-Belief Functional Health Pattern
Reports that her faith in God and the support of her church is central in her life.
Wears brown and green cloth scapulars. Watches TV Mass. Regarding medical
care, she reports she trusts her doctor even though he is fairly new to her and is
very young. She confides that the nurse listens more patiently and explains things like medications in a way Mrs. W can understand.
Assignment: Review data. Think about actual health problems and any risks for health problems of Mrs. Wisdom. Are her response patterns functional or dysfunctional? Highlight cues that indicate a problem. Use the NANDA manual to compare cues highlighted with problem statement, definition and defining characteristics/diagnostic cues or risk factors that would describe your concern.
Example: Beginning with her health perception-management fhp and her activity-exercise fhp, I note cues indicating a dysfunctional response to using health care system.
Cues: Functional Dysfunctional
Sees MD for prescriptions Goes to MD only if very ill
Going to eye MD re glare Treated self with fluid restriction
To MD for breathing difficulty
2 years since dentist, dentures
Does not know her own BP
Vague medication information
An in-class demonstration will illustrate how to establish a nursing diagnosis of this dysfunction.