Nathan Brown
Nursing 303-02
04102008
Nursing Process Paper
Health Perception-Health Management
When asked what brought him to be at this facility J responds “I had a CVA years ago.”
He has recovered from his CVA, but he had anxiety about having another and did not have
family to care for him fulltime. Since his initial admittance his DM II has worsened and he now
requires regular insulin injection. Additionally, he reported “I noticed my vision was changing,
but my Optometrist couldn’t find the problem.” “I finally went to a new doctor and she
diagnosed me with glaucoma, but I had nerve damage by then.”
When I asked J what goal I could help him achieve while I’m was with him eh responded
“I would like to get my strength back in my legs. I want to start walking again, with some help.
I’m worried about falling.” He reports that he has been using a wheelchair for almost a year
mostly because of anxiety about falling and has put on weight and does not feel as healthy
since.
J’s Genogram indicates a history of CVA, diabetes and gallbladder disease.
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Nursing 303-02
04102008
J reports “I do push-ups, sit-ups, and leg lift to stay healthy, but I don’t do them
consistently”. When I asked what interferes with his ability to keep healthy and follow medical
advice he said “lethargy.” He reports not having energy to get up and do things. J is usually does
not get up for the day until after lunch.
J is well aware of his current health situation. He reports noticing “a change in his
vision.” He was recently diagnosed with colon cancer and reported to me that he had “decided
to have surgery to remove the cancerous section.” “My doctor said there is about a 30%
chance I might not survive the surgery.” He did not entirely understand the need for a change in
his diet, form regular to liquid only, until after recovery his upcoming surgery.
J has a good history recall. He is able to remember details from his time before entering
nursing care. He is somewhat disoriented to time this morning. He reports “I didn’t sleep much
last night.” He ate breakfast in the dining room today and was talking with some of the other
patients about his upcoming surgery, and the chance that he might die, so did not sleep in as he
usually does.
J appears tired, but seems unable to relax. He is pulling at his beard or rubbing his legs
during our entire interview. He wears only a shirt during the interview and although he
apologizes for not having pants on he makes no effort to clothe himself. His hair and beard are
in disarray and he emanates a pungent body odor. The shirt he wears is wrinkled and appears
to be the same one he slept in. His posture is stooped with moderate kyphosis. When he
stands he must hold onto the bed rail for balance, but is able to support his weight. He is alert
and cooperative. His facial expressions are symmetrical and correlate with mood and topic
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Nursing 303-02
04102008
discussed. His speech is slightly slurred. He is oriented to person, place and events, but not to
time.
Nursing diagnosis: Readiness for Enhanced Knowledge related to diet and preparation
for upcoming abdominal surgery. As evidenced by the statement that he does not understand
why he can’t eat regular food before his surgery.
Nutrition/Metabolic
J has been in nursing care for almost 10 years. He is unable to recall specifics of his diet
pre-admission, but believes that his fluid intake was adequate and he admits that he probably
ate more that he needed. Since his diet is mostly controlled by the care facility his diet is well
balanced nutritionally, but is still more than his body requires calorie wise. He reports “I eat
breakfast, lunch and dinner every day, but sometimes I’m too tired to finish breakfast.” His
chart indicates that he eats 75-100% of all meals most days.
J reports no food allergies, and states “I am usually hungry at meal times.” He does “like
to have a Pepsi every day or so” and keeps gram cracker snacks in his bedside dresser for
snacking on. He feels that he is gaining weight and states “I need to get rid of some of this fat”
(referring to his abdomen). His weight records a weight gain of about 10 lbs in the last 12
months. His charts indicate a weight loss of 18 lbs the last 2 weeks. J.L reports having diarrhea
for the last week and half, and having black stool on Friday March 28th, which led to the
discovery of his colon cancer.
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Nathan Brown
Nursing 303-02
04102008
J has dentures but does not wear them. His lips are dry and pale red. No lesions or
ulcerations. His gums are pink and moist without discoloration, or bleeding. Hard and soft
palates are smooth and without lesions.
His skin is pale pink, warm and dry to the touch. Skinfold returns to place after 1 second
when lifter over clavicle. Tan and brown age spots on dorsal surface of both hands and distal
forearms. Patient has neuropathic discoloration, light and darker pink patches on dorsal surface
of feet bilaterally. Sores on both feet are healing well. Scabs are intact no redness or swelling
noted and new skin is pink and dry. Hair is about 2-3 inches long light to medium gray with
alopecia on crown of head. No scalp lesions of flaking noted. Finger and toenails are long thick
and yellowish in color.
Patient’s abdomen is rounded with out masses, lesions or pulsations. No bruising or
increased vasculature. Umbilicus is midline with out herniation swelling or discoloration. Bowel
sounds noted in all quadrants 3-30 per minute. No organomegaly noted with palpitation.
Tympany percussed over all four quadrants.
Patient’s dietary intake has been adequate. His diet is well balanced, with a good mix of
fruit and vegetables. However, his ongoing diarrhea has not allowed for adequate digesting and
absorption of calories and nutrients, leading to sever weight loss over the last 2 weeks. J’s diet
was changed to a full liquid diet and he will need to be NPO after midnight Thursday in
preparation for his abdominal surgery.
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Nathan Brown
Nursing 303-02
04102008
Nursing Diagnosis: Imbalanced Nutrition Less than Body Requirements related to
inability to absorb or metabolize foods. As evidenced by unintentional weight loss of 18 lbs,
and persistent diarrhea.
Cognitive/Perceptual
J reports “difficulty seeing more than 10 feet” and “I can’t tell people apart until they
are about 5 feet away.” He has a medical diagnosis of glaucoma and has vision loss due to nerve
damage. He reports that he has “had laser vision correction, but they couldn’t do anything
about the nerve damage.” When asked about his hearing he said “my hearing is fine, I haven’t
had any trouble there.” He reports that he can “only read the special large print book or listen
to books on tape.” He reports that he enjoys reading and writing, and “still occasionally writes
legal briefs.” He has no trouble comprehending either written or spoken language.
When I asked him which methods he felt helped him learn best he responded “since my
vision went bad I do better with auditory listening and memory recall.”
J feels that he “has a high threshold for pain” and is able to “tolerate pain well.” He told
me “I don’t like to take pain medication. I don’t want to become dependant to it. I usually
react to pain by trying to ignoring it.”
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Nathan Brown
Nursing 303-02
04102008
When I asked him about changes in his memory, learning abilities or decision making he
responded that he “[has] not noticed any changes in my memory or my ability to learn. I can
understand what I am told and make decisions based on that information.”
J is well oriented to himself, his environment and events. He is having difficulty keeping
tack of time today. He is able to communicate his need clearly. He is pleasant and friendly. He
follows through with train of thought and carefully chooses word to convey feeling and ideas.
Short and long term are memory intact. General information questions answered correctly
100% of the time. Vocabulary is suitable for education level.
When I tested J vision he had great difficulty with peripheral vision bilaterally. He could
not detect movement until it was within 40-50 degrees. He could not read a newspaper at any
distance and vision was blurry more than 5 feet away.
Nursing Diagnosis: Disturbed Sensory Perception: Visual related to diabetes, glaucoma,
and advanced age. As evidenced by reduced near vision, peripheral vision and poor visual acuity
beyond 5 feet and patient statement “I feel like my vision is getting worse.”
Self-perception/Concept/Role Relationship
When I asked J how he feel about himself and any changes he is experiencing he stated
that he feels “frustrated with [his] vision loss. I don’t know what I’ll do if I go completely blind.”
He also stated a desire to loose weight. “I want to get rid of this extra weight and get my
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Nursing 303-02
04102008
strength back, especially in my legs.” He seems fatalistic about his upcoming surgery. He said “I
know there’s a chance I might not survive my surgery, but I don’t worry about death. I feel like
I’ve accomplished the things I wanted to.”
When I asked J about changes in the things he can do and the problems this causes he
told me he feels frustrated with himself. He is upset that he let his anxiety get the better of him,
now he regrets “using a wheelchair instead of [his] walker.” He finds it difficult now to get
enough exercise because of his fatigue and inability to ambulate.
J frequently feels “angry and annoyed.” He also fell anxious often. He said “I feel like a
square peg in a around hole.” He says he uses “transendendtal relaxation to help relive [his]
anger, frustration and anxiety.” He also “fantasize[s] about returning to Boston.” J. has been in
nursing care for a long time, and does not expect to be released to home care. He told me “I do
not get along well with my roommate.” Because he is confined to one half of a room he does
not have enough space for all of his personal items. Today he was distressed because while he
was in the hospital the night nurse had “cleaned his room” and many of his personal items had
been discarded. He “feel[s] like [he is] not in control of [his] own life.”
When I asked J about his family he told me that he has “two sons, one here in Salt Lake
and one back in Boston” where he used to live. Both of his sons visit him in the care center.
“The one who lives here sees me at least once a week.” And his son in Boston “visits about 3 or
4 times a year.” His son here is a doctor and keeps up to date on his medical status. J. is “[has]
been divorced for 20 years.” He does not have any contact with his ex-wife.
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Nathan Brown
Nursing 303-02
04102008
When I asked J about his former occupation he said “he is a retired professor of law and
philosophy at Brown University” in Rhode Island. He “enjoyed being a teacher” and also “wrote
briefs for court cases and did some pro bono work when [he] had the time.” Since retiring he
has “written some court briefs and many short stories, a few of which were published in
national magazines.”
J told me that his most significant relationships “where those [he] had with his sons,
especially the son who lives in town. That is one of the reasons [he] moved out here form
Boston.” He said he “also [has] several good friends here in the care center, but that many of
the people I spend time around and not people that I would normally associate with.” As a
result he often spends a “fair amount of time in [his] room listening to books and watching
news and political programs.”
I asked J about his cultural and religious background. He told me that he considers
himself non-religious. He said “I believe in the power of the mind.” He said he does not have
any major cultural beliefs “aside from those of a lawyer.” Having spent much of his life on the
east coast he does think he leans toward the high stress and fast pace life style that is
predominant there.
Based on my interactions with J I feel that he falls into stage eight of Erickson’s theory of
development. Stage eight, maturity, which most 65+ adults fall into, is a time of either ego
integrity or despair. WJL appears to be satisfied with his life accomplishments and has a sense
of fulfillment. Based on Erickson’s theory it would be expected that he will accept death as an
unavoidable reality with dignity if he feels fulfilled in life. When I asked about his upcoming
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Nathan Brown
Nursing 303-02
04102008
surgery he said “I know there is a chance I might die, but I fell satisfied with my
accomplishments. I’m not afraid of what will happen when I die.”
J’s mood is generally good, he try’s to remain upbeat and maintain a positive affect.
Today he is obviously concerned about his upcoming surgery and feels that some of the staff at
the facility have done him wrong by removing his personal affects. He is happy to have
someone to talk to, but is obviously not used to the amount of attention that I have been able
to give him. He commented several times that he didn’t want to keep me and that he was sorry
for taking so much of my time, even after I explained to him that he was my only patient and
that I had plenty of time.
I believe that J has a disturbed self image. He seems unhappy with his appearance, and
does not feel that he has much control over his life. I think that he chooses not to bathe or
shave as a means of exerting some control over his life. J also as a tendency toward depression
and I believe along with his lethargy he sometimes doesn’t have the energy to do anything
extra.
Nursing Diagnosis: Self Care Deficit related to depression and feelings of not being in control. As
evidenced by foul body odor, untrimmed beard and nails and patients refusal to bathe.
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