Client Demographics:
· 84 year oldfemale
· MedicalHistory: Advanced COPD, Heart Failure, Hypertension, GERD
· Psychosocial:Lives by herself, but her daughter and daughter’s family livesnearby and often checks on the client. The client has discussed thepossibility of hospice care with her primary care provider due tothe advanced COPD, but has not discussed this with her family. Theclient’s daughter and family often cook for client and groceryshops for her. She states that she rarely finishes all food sheprepares as she is so tired.
· Physical data:5 ft. 5 in., 105 pounds
· VS: 130/82 BPsitting, 82 HR 26 RR SaO2 92% O2 at 1L 98.6 F oral
24 hr Food Recall:
· Breakfast: 1hardboiled egg with salt and pepper, 2 sausage links, 1 piece ofwhite toast 1T. Strawberry jelly, 12 oz. blackcoffee
· Lunch: 1package Lean Cuisine spaghetti with meat sauce (frozen meal), 1medium apple, 1 cupof 2% milk
· Afternoonsnack: 1/2 c. salted peanuts and raisins
· Dinner/Supper:3 oz. grilled chicken breast, 1/2 c. canned peas, ½ c. wild ricepilaf, 6 oz. 1% milk, ½ c. lemon sherbet
· Evening snack:2 cups of microwave popcorn
Include the citations for your rationales andreference list at the end.
Assessment: Complete with regards to respiratory and cardiacdiet recommendations.
1. Does the client have an appropriate amount of fluid intake?Why or why not? How does her medical condition influence her fluidintake?
Diagnosis: Based on the question given above to complete:
What problem or risk is presenting for this client?
Planning:
List one outcome for this client based on the problem orrisk.
Interventions:
List two interventions for the outcome. Be specific andindividualize to this client. Remember that the intervention shouldhelp to “solve” the problem or reduce the risk factors that wereidentified in the assessment and be designed to reach theoutcomes.
