Read the following case study.  Use the data that is gathered during your assessment to prioritize and plan your interventions for this patient

Kelly Neuman is a 55 year old male who is into your clinic for his yearly check up.  You are performing an assessment to determine his level of health and discover any health related problems.  Kelly tells you that he has no chronic medical conditions, but has a family history of coronary artery disease.  Both parents died at early ages (49 and 50) due to MI’s. 

 

You perform a physical assessment and get the following information:

Height: 5'10''

Weight: 300 pounds

BP 160/95, pulse 86, Respiration 16

Alert and oriented

Heart sounds within normal limits, regular

Lungs are clear bilaterally

Abdomen is rounded, bowel sounds present in all four quadrants, no tenderness on palpation

No edema is noted in extremities

Strength and mobility appear within normal limits

 

While you are performing your assessment you are talking with Kelly and get the following subjective information:

Kelly does not smoke.  He states he eats mostly fast foods as he is not married and doesn’t have the time to cook.  He does not take vitamins and has been on no special diet.  He denies difficulty eating/swallowing. 

 

Kelly states he does not have a regular exercise routine and what he prefers is to watch sports on T.V.  He tells you he has not trouble completing his activities of daily living, although he does get short of breath when climbing stairs.  He has a sedentary job (he is a computer programmer).  He has no problem with falls.

 

Kelly states his vision is good with his current prescription and he denies problems with hearing.  He denies any pain at this time. 

 

Kelly does state he has had some difficulty sleeping recently.  He states he is very stressed over his current work assignment and can’t seem to relax before bed.  He tells you his normal method of coping (talking to friends) is not working.  He states two of his closest friends have recently moved.  Due to his sleep difficulty, Kelly tells you he has been having a glass of wine before bed which helps him get to sleep, but he has been noticing he awakes at about 3 am and is unable to return to sleep.