Sexuality-Reproductive Pattern Paper

Sexuality-Reproductive Pattern: Client not sexually active for about 2 years

Pattern of Elimination: Constipation, takes Colace and eats salad to help with bowel movement

Pattern of Activity and Exercise: Client is active, goes to the gym at least 3x weekly before her back injury. Still goes to work on modified duties.

Pattern of Sleep and Rest: Client does not rest during the day and gets about 6 hours of sleep at night.

Pattern of Self-Perception and Self-Concept: Client has gained a lot of weight of late and was doing well with weight control by going to the gym but now with her back hurting, not sure when to go back. Client is very concern and worried about her situation; Client reassures herself that she’s doing her best to help her children but must be healthy for this to continue.

Summarize
Your Findings
(Use format that provides logical progression of assessment.)
Situation (reason for seeking care, patient statements): Client is 42years old seeking care because of her BP and her back pain.

Background (health and family history, recent observations):

Client is a 42-year-old AA female who is separated but has custody of their 5 children. Client stated that she’s going through a lot of stress that is affecting her health. Stress from work, family and state of health. She’s a nurse manager in a local hospital and recently hurt her back while helping a staff pull a patient. Her physical therapist is suspecting bulging disc but there has been a delay in obtaining authorization from the workman comp for an ordered MRI lumber spine. She’s been on Motrin, flexeril and TENS for pain management. Client has high BP but stated that she has not taken her BP med in over a week because her insurance company sudden changed her med to generic which she reacted to in the past. If she must continue to take the current med, her copay would be $1000.00 for 90 days’ supply. She just got some samples from her PCP 2 days ago and is trying to resolve this issues with her insurance company. Vitals are BP 160/90, HR 74, RR 20 Temp 97.8, pain 9/10 on lower back and recent A1c of 8.3
Client has history of HTN, DM and High Cholesterol.
Surgical history includes appendectomy, hysterectomy, right breast biopsy, C-Section 2006 and 2008. Patient currently takes orally Benicar/HCTZ 40/25mg daily, Metformin 500mg BID, Atorvastatin 20mg daily, Motrin 600mg Q6 hours as needed for pain, Flexeril 10mg BID and Colace 100mg daily.
Mother has DM and Father died of CVA.

Assessment (assessment of health state or problems, nursing diagnosis):

Client is a bit anxious with facial grimacing when moving from a sitting to standing position, BP elevated at 160/90, able to stand or sit straight but musculoskeletal assessment of the lower extremities reveals difficulties with mobility, experiences great pain and discomfort when attempting to looking down, bend, sit for a long time or reach down. There was no problem with upper extremities.
Client is having pain related to lower back injury as evidenced by compliant of pain level of 9/10
Risk for fall or injury related to pain and weakness of right lower extremity
Constipation related to inadequate diet as evidenced no irregular bowel movement.
Ineffective coping related to stress as evidenced by
separation.

Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education):
Client to change position frequently to relieve pain, take pain meds as ordered. Client to ambulate with caution and to hold unto furniture if needed to prevent fall or injury. Client to increase intake of fruits, vegetables and fibers to prevent constipation and low salt intake to help to help with BP. Client to seek for assistance from families and friends to help with coping mechanism. Other education includes taking all meds as prescribed, checking BP and blood sugars daily, doing exercises as recommended by PT. Client to also follow up with PCP to help facilitate authorization of MRI.