Data for Margaret, Organized According to Functional Health Patterns

NURSING PHYSICAL ASSESSMENT MEDICATION/HISTORY

• 33 years old • Synthroid 0.1 mg per day
• Height 158 cm (5 ft, 2 in.); weight 56 kg (125 lb) • Client has history of appendectomy, partial thyroidectomy
• TPR 39.4°C (103°F), 92 beats/min, 28/min
• Radial pulses weak, regular
• Blood pressure 122/80 mmHg sitting
• Skin hot and pale, cheeks flushed
• Mucous membranes dry and pale
• Respirations shallow; chest expansion, 3 cm
• Cough productive of small amounts of pale pink sputum
• Inspiratory crackles auscultated throughout right upper and lower chest
• Diminished breath sounds on right side
• Abdomen soft, not distended
• Old surgical scars: anterior neck, RLQ abdomen
• Diaphoretic
HEALTH PERCEPTION/HEALTH MANAGEMENT NUTRITIONAL/METABOLIC
• Aware/understands medical diagnosis • 158 cm (5 ft, 2 in.) tall; weighs 56 kg (125 lb)
• Gives thorough history of illnesses and surgeries • Usual eating pattern “three meals a day”
• Complies with Synthroid regimen • “No appetite” since having “cold”
• Relates progression of illness in detail • Has not eaten today; last fluids at noon
• Expects to have antibiotic therapy and “go home in a day • Nauseated
or two” • Oral temperature 39.4°C (103°F)
• States usual eating pattern “three meals a day” • Decreased skin turgor
ELIMINATION ACTIVITY/EXERCISE
• Usually no problem • No musculoskeletal impairment
• Decreased urinary frequency and amount × 2 days • Difficulty sleeping because of cough
• Last bowel movement yesterday, formed, states was • “Can’t breathe lying down”
“normal” • States “I feel weak”
• Short of breath on exertion
• Exercises daily
COGNITIVE/PERCEPTUAL ROLES/RELATIONSHIPS
• No sensory deficits • Lives with husband, 13-year-old daughter, and 5-year-old son
• Pupils 3 mm, equal, brisk reaction • Husband out of town; will be back tomorrow afternoon
• Oriented to time, place, and person • Children are with their grandparents until husband returns
• Responsive, but fatigued • States “good” relationships with friends and coworkers
• Responds appropriately to verbal and physical stimuli • Nursing student and part-time home health aid
• Recent and remote memory intact
• States “short of breath” on exertion
• Reports “pain in lungs,” especially when coughing
• Experiencing chills
• Reports nausea
SELF-PERCEPTION/SELF-CONCEPT COPING/STRESS
• Expresses “concern” and “worry” over leaving her children with • Anxious: “I can’t breathe”
their grandparents until husband returns • Facial muscles tense; trembling
• Anxiety related to missing her nursing classes, missing her • Expresses concerns about work: “I’ll never get caught up”
medical–surgical clinical day, and inability to study
• Well-groomed; says, “Too tired to put on makeup”
VALUE/BELIEF
• Catholic
• No special practices desired except anointing of the sick
• Middle-class, professional orientation
• No wish to see chaplain or priest at present