Ms. Sato is a 75-year-old Japanese American who speaks Japanese as a primary language but is proficient in reading/writing English. She recently moved to a long-term care facility as she
was unable to adequately take care of herself at home. Ms. Sato is divorced and was a
housewife and caregiver for a son diagnosed with cystic fibrosis and type 1 diabetes at a young age. Her
two daughters live nearby and visit each week. Her past medical history includes colon CA, colostomy,
Helicobacter pylori infection, depression, hypertension, and osteoporosis. She wears glasses for reading.
Orders include:
Full resuscitation
Regular diet
Ambulate with gait belt and 1 standby assist
PT/OT daily
Change ostomy appliance PRN
Psychiatry consult
Medications Include:
Sertraline 50 mg PO daily
Alendronate 10 mg PO daily
Cholecalciferol 1 capsule (5,000 IU) daily
Metoprolol ER 100 mg PO daily
Clonidine 0.1 mg PO TID
Module 07 Content
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: You will complete a health history, physical assessment of your client, and nursing diagnoses in this second submission of your Course Project. The following should be included in this written assignment:
Health Assessment, Health History, and Nursing Diagnosis
A brief medical/health history
Summary of laboratory diagnostic results related to the illness/condition and what they mean
Summary of a head to toe physical assessment
Your nursing diagnosis
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