A Study On Patient History Essay

934 Words Oct 10th, 2016 4 Pages
Patient History Mary is a 77-year-old female who was recently diagnosed with a rare esophagus, achalasia. Achalasia is a disease that prevents relaxation of the lower muscle in the esophagus. Mary was having trouble swallowing her food, having quite intense chest pain and when she was able to eat she was having trouble keeping the food down. Just a few weeks after her diagnosis, Mary was having continued issues with swallowing and shortness of breath. Upon doing an x-ray doctors found food stuck in her esophagus that was causing infection and immediately started antibiotics. Previously to this diagnosis, Mary lived at home with her husband of over 50 years in a two story home in Florence, Cape Breton. Mary has also been living with rheumatoid arthritis for 30 + years which has caused a decline in her ability to use her hands. Before her rheumatoid arthritis flared up she enjoyed quilting, knitting and shopping. Mary also enjoys reading but has a hard time seeing small print. Mary and her husband enjoy going out to dinner, the casino and the legion to socialize with friends but has been in hospital over a month which has caused a decline in her mobility.
Goal Statements/Care Plan
1. Maintain engagement in one leisure activity that was previously enjoyed
-Ask patient what books she is interested in reading
-Upload books to patients Kobo (e-reader)
-Teach patient how to use device
2. Reduce anxiety related behaviours
-Engaged patient in guided relaxation techniques

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