Question

PROFESSIONAL NURSING 1 CLINICAL MAKE-UP

            Robert Reynold, a 42-yr old university professor, presents for a check-up shortly after his father’s death. His father died of complications of Coronary Artery Disease (CAD). Mr. Reynold is 5 feet 9 inches tall, weighs 235 pounds and reports that until now he has made no time for exercise because he preferred to use his free time reading or listening to classical music. He enjoys French Cuisine, including rich deserts, and has a total cholesterol level of 310 mg/dl. He admits being frightened by his father’s death and is concerned about his elevated cholesterol level. “I guess I’ve never given much thought to my health before, but my dad’s death changed all that,” he tells you. “I know that CAD runs in my family, and I can tell you that I am not ready to pack it all in yet. Tell me what I have to do to fight this thing.” He admits that he used to tease his colleague, who lowered his own cholesterol from 290 to 200 mg/dl by diet and exercise alone, by accusing him of being a fitness freak. “Now I am recognizing all the wisdom of his behaviors and wondering if diet and exercise won’t do the trick for me. Can you help me to design an exercise program that will work?”

1.      Identify pertinent objective and subjective data in this case study.

2.      State the health problem, related factors, signs and symptoms, goal and nursing interventions.

3.      Assume that you are performing a nursing assessment on this patient. Document your findings.

Answer 1

1. PERTINENT OBJECTIVE AND SUBJECTIVE DATA :

OBJECTIVE DATA :

• Patient is overweight.
• Anxiety.
• Total cholesterol level - 310 mg/dl.

SUBJECTIVE DATA :

• Patient admits that his weight is 235 pounds.
• History of CAD in the family concerns him which lead him to the clinic, therefore he could also have anxiety.

2. RELATED HEALTH FACTORS :

• Diabetes mellitus.
• Hypertension.
• Cornonery artery disease.
• Artherosclerosis.
• Metabolic disorders.
• Cancer.
• Stroke.
• Renal disease.

3. NURSING ASSESSMENT :

• Height - 5 feet 9 inches tall.
• Weight - 235 pounds.
• Family history of CAD.
• Total cholesterol level - 310 mg/dl.
• Face appears worried regarding health issues.