Patient: Fang Cai Hua

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Patient: Fang Cai Hua by Mind Map: Patient: Fang Cai Hua

1. Daily Living Patterns

1.1. Morning Routine

1.1.1. Wakes at 6 AM.

1.1.2. Breakfast: 7 AM (congee, eggs, milk).

1.2. Midday Activities

1.2.1. Sunbathing, walking, chatting with friends (8:30–11:00 AM).

1.2.2. Lunch: 11:00–12:00 PM.

1.2.3. Rest, walking, TV, or chatting (12:00–4:30 PM).ities:

1.3. Evening Routine

1.3.1. Dinner: 4:30–5:30 PM..

1.3.2. Walks or chats with husband (5:30–6:30 PM).

1.3.3. TV and bath before bed (6:30–8:00 PM).Routine

1.4. Sleeping Habits

1.4.1. Bedtime: 8 PM. Sleeps 9–10 hours, wakes twice at night but falls asleep easily.

2. Nursing Diagnoses

2.1. **Lack of Knowledge About Medication Side Effects**

2.1.1. Subjective Data

2.1.1.1. Patient unaware of potential medication side effects.

2.1.1.2. Questions the long-term risks of treatment.

2.1.2. Objective Data:

2.1.2.1. Blood pressure (132/83 mmHg) is controlled.

2.1.2.2. Medications taken regularly but with minimal engagement in health discussions.

2.1.3. Goals:

2.1.3.1. Short-Term:

2.1.3.1.1. Identify 3 common side effects of medications within 1 week.

2.1.3.1.2. Begin monitoring and logging blood pressure daily.

2.1.3.2. Long-Term:

2.1.3.2.1. Demonstrate proactive communication with healthcare providers.

2.1.3.2.2. Achieve consistent BP readings below 140/90 mmHg for 4 weeks.

2.1.4. Interventions:

2.1.4.1. Provide educational materials (e.g., booklets, videos) tailored to elderly patients.

2.1.4.2. Teach proper use of a blood pressure monitor through live demonstrations.

2.1.4.3. Conduct weekly Q&A sessions to clarify medication-related concerns.

2.1.4.4. Set up a medication reminder system using alarms or visual aids.

2.1.4.5. Involve family in health discussions to reinforce understanding and support.

2.1.5. Evaluation:

2.1.5.1. Patient demonstrates knowledge of 3 medication side effects (e.g., dizziness, nausea).

2.1.5.2. Maintains a complete BP log for 10 consecutive days.

2.1.5.3. Actively engages in healthcare discussions by asking 3+ questions per session.

2.2. **Risk of Falling**

2.2.1. Subjective Data

2.2.1.1. Complains of fatigue and weakness during prolonged activity.

2.2.1.2. Relies on a walker due to mobility challenges.

2.2.2. Objective Data:

2.2.2.1. Johns Hopkins Fall Risk Assessment: Moderate (score: 9).

2.2.2.2. Poor balance, slow walking (12 seconds for 4m), and weak lower limb strength (sit-to-stand: 18 seconds).

2.2.3. Goals:

2.2.3.1. Short-Term

2.2.3.1.1. IIdentify 2 personal and environmental fall risks within 2 weeks.

2.2.3.1.2. Improve balance and mobility test times by 3 seconds in 4 weeks.

2.2.3.2. Long-Term:

2.2.3.2.1. Increase daily activity by 30 minutes using proper mobility aids.

2.2.3.2.2. Ensure no falls occur within 8 weeks.

2.2.4. Interventions:

2.2.4.1. Modify the living environment: clear clutter, add handrails, and secure rugs.

2.2.4.2. Create a personalized exercise plan focused on lower limb strength and balance.

2.2.4.3. Train on proper use of walking aids for maximum stability.

2.2.4.4. Encourage daily light activity with scheduled reminders.

2.2.4.5. Collaborate with physical therapists for supervised rehabilitation exercises.

2.2.5. Evaluation:

2.2.5.1. Patient identifies and avoids 2 fall risks (e.g., cluttered walkways, slippery floors).

2.2.5.2. 4-meter walk test improves from 12 to 9 seconds.

2.2.5.3. Sit-to-stand test improves from 18 to 14 seconds.

2.2.5.4. Increases daily activity by 30 minutes without signs of fatigue or imbalance.

2.2.5.5. Maintains a fall-free record during the intervention period.

2.3. **Loneliness**

2.3.1. Subjective Data

2.3.1.1. Feels lonely due to limited interaction with her daughter.

2.3.1.2. Avoids community activities despite having friends.

2.3.2. Objective Data:

2.3.2.1. UCLA Loneliness Scale: Moderate (score: 55).

2.3.2.2. Minimal participation in group activities.

2.3.3. Goals:

2.3.3.1. Short-Term

2.3.3.1.1. Reduce UCLA Loneliness Scale score to below 45 within 1 month.

2.3.3.1.2. Increase social interactions by initiating conversations with 3 peers daily.

2.3.4. Long-Term:

2.3.4.1. Regular participation in 1 group activity per week.

2.3.4.2. Strengthen family communication with at least 3 calls per week.

2.3.5. Interventions:

2.3.5.1. Schedule and teach video calling with her daughter.

2.3.5.2. Plan group activities aligned with her interests (e.g., storytelling, crafting).

2.3.5.3. Organize monthly family meetings to discuss progress and support strategies.

2.3.5.4. Set small daily social goals (e.g., greet and talk to 3 peers during meals).

2.3.5.5. Facilitate peer group discussions on shared experiences (e.g., aging challenges).

2.3.6. Evaluation:

2.3.6.1. UCLA Loneliness Scale score decreases to 42 or below.

2.3.6.2. Patient actively participates in weekly group activities.

2.3.6.3. Engages in 3 family calls weekly with shared meaningful interactions.

2.3.6.4. Successfully initiates daily conversations with at least 3 peers.

3. General Information

3.1. Name: Fang Cai Hua

3.2. Age: 67

3.3. Gender: Female

3.4. Current Living Situation: Nursing Home: 1.5 years, private room.

3.5. Contact: Daughter (Emergency Contact)

3.6. Health History

3.6.1. Hypertension (13 years).

3.6.2. Epilepsy (1.5 years).

3.6.3. Past fracture repair (3 years ago).

3.7. Medications:

3.7.1. Carbamazepine 100 mg BID (antiepileptic).

3.7.2. Amlodipine 10 mg QD (antihypertensive).

4. Gordon Functional Health Patterns

4.1. 1. Health Perception–Health Management

4.1.1. Subjective Data

4.1.1.1. Generally feels okay but uses a walker.

4.1.1.2. Follows light diet and takes medication regularly.

4.1.1.3. Lacks knowledge of medication side effects.

4.1.2. Objective Data:

4.1.2.1. BP: 132/83 mmHg.

4.1.2.2. Moderate mobility issues.

4.1.3. Summary: Needs education on medication side effects and proactive health monitoring.

4.2. 2. Nutritional-Metabolic

4.2.1. Dietary Habits: Balanced meals with low salt.

4.2.1.1. Daily protein powder (150-200 ml).

4.2.2. Hydration: Drinks ~1000 ml of fluids/day.

4.2.3. Physical Signs:

4.2.3.1. Dry skin, normal BMI (23), good appetite.

4.2.3.2. All teeth replaced by dentures.

4.2.4. Summary: Well-nourished; no issues noted.

4.3. 3. Elimination

4.3.1. Urination: 5-7 times/day, light yellow color

4.3.2. Defecation: Once every two days; normal stool form and color.

4.3.3. Summary: No elimination issues.

4.4. 4. Activity Exercise

4.4.1. Energy: Tires after prolonged activity.

4.5. 5: Sleep-Rest

4.5.1. Duration: 9–10 hours/night.

4.5.2. Quality: Good; no trouble falling asleep or staying asleep.

4.5.3. Summary: No sleep issues.stPattern6: Cognitive-Perceptual

4.6. 6: Cognitive-Perceptual

4.6.1. Subjective Data: Memory intact; consults family for major decisions.

4.6.2. Objective Data: Vision, hearing, and cognition normal.

4.6.3. Summary: No cognitive issues.

4.7. 7: Self-Perception–Self-Concept

4.7.1. Attitude: Optimistic and proactive.

4.7.2. Concerns: Occasional worry about illness recurrence.

4.7.3. Summary: Positive self-image.

4.8. 8: Relationship

4.8.1. Family: Feels lonely due to limited interaction with daughter.

4.8.2. Social: Engages with husband and peers but avoids group activities.

4.8.3. Summary: Moderate loneliness.

5. Daily Routine

5.1. Morning Activities:

5.1.1. Wakes up at 6 AM, begins the day with light stretches or sunbathing.

5.1.2. Breakfast at 7 AM: A light meal of congee, eggs, and milk (200 ml).

5.1.3. From 8:30 to 11:00 AM: Engages in social interactions such as chatting with friends or walking outdoors for 10–15 minutes every hour.

5.2. Midday Activities:

5.2.1. Lunch at 11:00 AM: Balanced meal including rice, vegetables, and lean protein (300–400 g).

5.2.2. From 12:00 to 4:00 PM: Alternates between light activities (e.g., watching TV, chatting) and rest periods to conserve energy.

5.2.3. Drinks protein powder (150–200 ml) in the afternoon as a snack.

5.3. Evening Activities:

5.3.1. Dinner at 4:30 PM: A light meal of congee and vegetables (150–200 g).

5.3.2. Walks or chats with her husband from 5:30 to 6:30 PM, enjoying companionship and mild physical activity.

5.3.3. Watches TV or listens to the radio from 6:30 to 7:00 PM.

5.4. Night Routine:

5.4.1. Bathing: 7:00–7:30 PM.

5.4.2. Bedtime: 8:00 PM, ensuring 9–10 hours of sleep.

6. Current Treatment Plan

6.1. Medications

6.1.1. Amlodipine: 10 mg once daily after breakfast for hypertension.

6.1.2. Carbamazepine: 100 mg twice daily (post-meal) for epilepsy.

6.2. Monitoring:

6.2.1. Daily blood pressure measurements recorded in a log.

6.2.2. Monitoring for signs of dizziness, nausea, or fatigue as potential medication side effects.

6.3. Dietary Adjustments:

6.3.1. Follows a low-salt, low-fat diet to control hypertension and prevent complications.

6.3.2. Incorporates fresh vegetables, lean protein, and limited carbohydrates in each meal.

6.4. Physical Activity:

6.4.1. Regular walking for 10–15 minutes every hour during the day to maintain mobility and improve circulation.

6.4.2. Exercises for balance and strength to reduce fall risks, guided by her physical therapist.

6.5. Social and Emotional Well-Being:

6.5.1. Engages in group activities and social interactions as part of her care plan.

6.5.2. Maintains regular communication with her daughter to reduce feelings of loneliness

6.6. Support from Family and Nursing Staff:

6.6.1. Family involved in reminders for medication adherence and emotional support.

6.6.2. Nursing staff ensures a safe environment and assists with mobility aids as needed.