Mrs. Jones, an 80-year-old Caucasian female adult presents to her family physician’s office with complaint of increased heart burn. She has been using Mylanta to hold it in check, but recently, it
has not let up. “I try to take care of myself. When I couldn’t stop the heart burn from coming back, I made an appointment with you folks.” The nurse has Mrs. Jones get on the scale and also does a
height measurement. The client is questioning the correctness of the height measurement.
The nurse has her medical folder with prior history and medication information and reviews it with the client. The only new findings are the heart burn and height.
Vital signs, weight, and height are checked for the current visit.
HR-80, BP-122/84, RR-18, Temp-98.4, Weight-145 lbs., Height-5ft 4.5in.
History & Medications on File
-A fall at home two years ago resulted in a fracture of the right radius and ulna. Casting was 4.5required for three months.
-Chronic arthritis: Managed with Advil. Severe bouts of pain (x3 in last 10 years) has required an injection of a glucocorticoid.
-Breast cancer 20 years prior. Treated successfully with chemotherapy and radiation.
-Occasional sinus infections. Managed with Sudafed.
-Previous Vitals: HR-78, BP-119/80, RR-18, Temp-98.4, Weight-142 lbs., Height-5ft, 6in.
-OTC: Advil, Mylanta, Sudafed
Investigational Questions / Statements:
1. Physiology – Discuss conditions that contribute to osteoporosis.
2. Assessment – Discuss test(s) that screen for osteoporosis.
3. Diagnosis – Provide one (1) nursing diagnosis and one (1) collaborative diagnosis. The
nursing diagnosis should include ‘related to’ factors and ‘as evidenced by’ for support.
You may use bullet points to list the diagnosis.
4. Planning – What interventions will you use for your nursing diagnosis? (Remember that
teaching is an intervention.) What preliminary orders do you anticipate from the
5. Implementation – Which intervention is of most importance and why? Include any special
considerations or patient preparation you would keep in mind. How will you prepare your
patient for the physicians orders (labs, tests, etc.)?
6. Evaluation – What outcomes do you desire for your nursing diagnosis and interventions?
The Case Study is a scholarly writing and content assignment. Be sure to address each of the investigational questions in your content. Use the lead terms as subtitles (ie: Physiology, Assessment,
etc.). Please omit a generalized introduction and conclusion.
Use APA format to include: title page, reference page, in-text citations, double spaced lines, indentions, etc. (excluding an introduction and conclusion). Your submission should be between 3.5 to
4 pages (plus the title and reference pages). Please submit as one continuous document. Support your assertions with your text book plus at least one (1) evidence-based, peer-reviewed nursing
journal as indicated. A journal article should never be older than 5 years.