I'll try to make this brief. I'm in the 2nd month of my LPN program and we are doing our 1st care plan on a case study. I'll try not to only write the important things but here's the basics:
Assessment at free health fair. 82yo male, 5'11", 152lbs. Vitals: T 98.3 oral, P 92 strong & regular, BP 168/92, R 14 normal. Skin- pale, dry. Mucous membranes- dry. Appears tired and needs haircut.
Hx-high cholesterol, hypertension, cataracts, arthritis.
Med Hx- Lipitor, Lopressor, Ibuprofen. Current issues reported- weight loss approx 10lbs, reduced appetite- eats less than 50% of meals, fatigue, insomnia, nocturia, occasional urinary incontinence, slight unsteadiness ambulating (uses cane).
Retired warehouse worker, married 60y- wife has increasing dementia. Has not seen MD in years but reports keeping up w/ wife's medical appts. When asked about current meds, fidgets and states,"I'm glad my blood pressure was good at the last health fair, those pills are so expensive."
What I came up with is (I have no idea of I can even use this so I appreciate any criticism including "that's all wrong"!):
Hypertension, related to knowledge deficit regarding condition and therapeutic regimen, as evidenced by not seeing HCP and not continuing medication. (AEB in my own words- ?)
Imbalanced nutrition, less than body requirements, related to ineffective health management OR ineffective coping (wife w/ dementia and obvious concerns over expense of meds as a stress factor).
I'm concerned if these are worded and laid out correctly- especially if using my own wording in the AEB is OK. I know I still need to do interventions and goals, but I'm going one step at a time and hoping I'll start getting the hang of it as I go along. But first I need to know if I'm even on the right track.
Thanks for any guidance!