Module 07 Course Project – Health Assessment, Health History, and Nursing Diagnosis

Module 07 Content


  1. In this second submission of your Course Project, you will be completing a health history, physical assessment of your client and determining their nursing diagnoses. This written assignment should include the following:

    Health Assessment, Health History, and Nursing Diagnosis

    1. A brief medical/health history
    2. Summary of laboratory diagnostic results related to the illness/condition and what they mean
    3. Summary of a head to toe physical assessment
    4. Your nursing diagnosis
I have included the informnation of the patient to further assist you bjustvin case my paper was not as clear 

Course Project Case Study: Mrs. Mason is a 79-year-old African American female who resides
at an assisted living facility.  She is
widowed with one son who lives nearby. 
Her medical diagnoses include congestive heart failure, hyperlipidemia, depression,
atrial fibrillation, and hypertension.  Additional
past medical history includes gestational diabetes (40 years ago), chickenpox
as a child, and atelectasis (post-op in the past).  She worked as a secretary for the local
police department but has been retired for 15 years.  She ambulates independently with a walker and
standby assist and requires minimum assist during bathing.  For the past two weeks, she complains of
feeling short of breath and is unable to tolerate ambulating to the dining room
and around the facility.  She enjoys
attending group activities at the facility but has not joined the morning
exercise group for the past week.  She
has a recent weight gain of 2.5 kg. 

 

Orders include:

Do not resuscitate

Ambulate with walker and 1
standby assist

Daily
weights

NAS
diet

1.5L fluid restriction/24 hours

Medications Include:

Furosemide
20 mg PO daily

Warfarin
2 mg PO daily

Simvastatin
20 mg PO daily

Sertraline
100mg PO daily

Metoprolol 75 mg PO BID

 

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