Nursing Rogerian
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- Date Submitted: 12/07/2010 08:41 AM
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Rogerian Narrative Evaluation of Client
Patterning
The client’s chief concern at time of assessment was pain in her abdomen and middle back. She rated the pain as an ‘8’on the pain scale for her abdomen and a ‘6’ for her middle back. She says that the abdomen pain is from her having chronic pancreatitis. She has a pain pump and is prescribed Lora tab. The client states that both the medications “help a whole lot but there is still residual pain. She was admitted to long term care with her husband and remained here after he passed a year ago. She has inability to care for her apartment and her ADL’s so she would be safer with managed care.
Her other diagnoses include hypothyroidism, gastroesophogeal reflux disease, Christian-Weber disease, depression and constipation. With further assessment and patterning I learned that the client is very active physically, mentally and socially despite her condition. She was able to completely dress and groom herself in the morning. She enjoyed conversing with the other residents and with the health staff. She also takes many family vacations; with the next being a cruise in a month. I observed the client eating both her breakfast and lunch although she at 30% of her meals. The client told me that she “has not had an appetite for the last few days because she feels nauseas and her stomach hurts” Objective supportive information to the client’s stomach pain is her current prescription of Loratab and use of a pain pump. The day of care I asked if these medications helped she replied “oh yes, especially after I see the doctor and he refills my pain pump”.
When I spoke with her she was a very cognitive individual and was cohesive in her thoughts. She was alert and oriented to person, place and time and had a warm, friendly attitude. When I assessed her circulatory system I did not find any abnormalities, she had strong, equal pulses bilaterally, pulse of 78, and B/P of 138/82. She had clear lungs sounds and a respiratory rate...
Patterning
The client’s chief concern at time of assessment was pain in her abdomen and middle back. She rated the pain as an ‘8’on the pain scale for her abdomen and a ‘6’ for her middle back. She says that the abdomen pain is from her having chronic pancreatitis. She has a pain pump and is prescribed Lora tab. The client states that both the medications “help a whole lot but there is still residual pain. She was admitted to long term care with her husband and remained here after he passed a year ago. She has inability to care for her apartment and her ADL’s so she would be safer with managed care.
Her other diagnoses include hypothyroidism, gastroesophogeal reflux disease, Christian-Weber disease, depression and constipation. With further assessment and patterning I learned that the client is very active physically, mentally and socially despite her condition. She was able to completely dress and groom herself in the morning. She enjoyed conversing with the other residents and with the health staff. She also takes many family vacations; with the next being a cruise in a month. I observed the client eating both her breakfast and lunch although she at 30% of her meals. The client told me that she “has not had an appetite for the last few days because she feels nauseas and her stomach hurts” Objective supportive information to the client’s stomach pain is her current prescription of Loratab and use of a pain pump. The day of care I asked if these medications helped she replied “oh yes, especially after I see the doctor and he refills my pain pump”.
When I spoke with her she was a very cognitive individual and was cohesive in her thoughts. She was alert and oriented to person, place and time and had a warm, friendly attitude. When I assessed her circulatory system I did not find any abnormalities, she had strong, equal pulses bilaterally, pulse of 78, and B/P of 138/82. She had clear lungs sounds and a respiratory rate...