Client History Sample

Superior Essays
Client History
A.O. is an 89 year old Catholic female of Japanese background. Past marital status is unknown, currently unmarried. Currently on medication for hypertension which initially caused bradycardia until the dosage was lowered. A.O. was immunized as a child, did protract chicken pox. Measles, and mumps. Client stated no known allergies (although later stated taking OTC Zicam), no surgeries, and only one hospitalization for a broken toe. Father’s side has history of stroke, and hypertension. Mother’s side has a history of longevity. Starting approximately five years ago client’s family noticed signs of dementia. Also suffers from mild arthritis in right knee. Daily medication includes Diltiazem @ 120mg, and Hydrocodone. Over the counter medications include occasional use of Zicam, and Gas X as needed. Client is retired, living on the lower floor of family residence, family members provide care and meals. Overall health appears good, eats well, no elimination problems, sleeps well, does use FWW (since fall lead to broken toe) although she claims to not need it. Blood pressure is still elevated at 138/70, and heart rate is on the low side of normal at 62.
Nutrition
…show more content…
Has enjoyed noodles since she was young. Eats three meals a day and always has fruit for breakfast, and a salad with dinner. Does not experience any abdominal pain, heart burn, or nausea. Sense of taste and smell have decreased “a little”. Teeth are in very good shape with the exception of one front missing tooth. Would like to replace it, but stated “too expensive, so for now it’s a window”. No recent changes in weight, currently weighs 138 pounds at 5’ 1” tall for a BMI of 26.1 which is well above the malnutrition level of <21 (Giddens, 2013). Grocery shopping and cooking is performed by her sister who goes to the store twice a week. Given her age nutrition is considered

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