Helen McDonald 09/24/09 Write up #3 H.G. General Survey: Pt appears to be a slender, well developed 31 year old female.

Pt appears to be stated age. Pt skin color appears pink and dry. Pt is dressed appropriate for season. Pt has good hygiene. Pt behavior is appropriate with stated age. Pt ambulates with steady gait. Life styles and Health practices: 24 hr Nutritional Intake 0600- one 10oz coffee, 2 sugars, 2 creamers and 24oz of water. 1000- fiber one bar 1200- 1.5 cups of corn flakes with 3/4 cup of 2% milk and 12oz of water. 1800- 2 slices of cheese pizza and 8oz of regular pepsi 2000- 1 cup of Vanilla ice cream Comparing Pt 24 hr dietary intake to the food pyramid: -Pt is sufficient in grain intake. Food pyramid suggest 6oz of grains and make half your grains whole. -Pt is lacking in vegetable intake. Pt has had no vegetables intake. The food pyramid suggests 2.5 cups per day. -Pt is lacking in fruit intake. Pt has had no fruit intake. The food pyramid suggests 2 cups per day. -Pt is sufficient in milk and calcium intake. The food pyramid suggests 3 cups per day. -Pt is lacking in meat and bean intake. Pt has consumed no meats or beans. The food pyramid suggests 5 oz every day. -Pt is sufficient in intake of water. The food pyramid suggests 6, 8oz glasses of water per day. ND: Nutritional deficit related to dietary intake as evidenced by 24 hr nutritional intake. BMI: Height = 54 = 1.646m Weight= 125lbs = 56.7 kg BMI= 20.93

Description of typical day 0600- wake up, have coffee and shower 0730- get kids up and ready for school 0830- get kids on the bus 0845- exercise, takes a walk 1000- snack 1200- lunch 1230- school work and/or house work while the baby naps 1500- gets kids off the bus 1515- help kids with homework, packs lunches for next day 1600- plays with kids 1700- makes dinner 1730- has dinner with family 1800- cleans up after dinner, does dishes 1830- walks with family 2000- has a snack, gets kids ready for bed 2100- reads to children 2200- goes to sleep Nutrition: Pt states that she purchases and prepares most meals for her, her husband and two children. Pt states she is breast feeding her one year old son. Activity: Pt reports she exercises on a regular basis. She takes frequent walks at home alone and with her family in a quit safe, suburban neighborhood. Pt states she had a membership at Planet Fitness but recently stopped her membership because of childcare reasons. Sleep: Pt states she gets 8 hours of sleep most nights. Pt states she wakes up at 0600 regardless of what time she falls asleep. Pt denies any sleeping problems. Medications: Pt states she takes one multivitamin daily. Pt states she takes no other prescription or over the counter medications. Pt denies use of alcohol and illicit drug use. Self concept: Pt states, I have a good self concept.

Self-care responsibilities: Pt is able to perform all activities of daily living independently. Social activities for fun and relaxation: Pt enjoys playing with her children and going for walks. Pt states she enjoys reading for relaxation. Social activities contributing to society: Pt volunteers for the March for Babies. She is a group leader. Relationships: Pt has a good relationship with her husband, children and cat. Religion/Spirituality: Pt states she is Catholic and values her faith. Education: Pt graduated from high school with a high school diploma. Pt has an associates degree in science and is a Registered Nurse. Pt is currently enrolled in SunyITs satellite program for her bachelors in Nursing. Pt is taking classes part time and generally one class a semester. Pt states she would like to pursue her nurse practitioner. Career: Pt is currently working part time as and RN at Bellevue Womans Hospital. pt states she enjoys her job. Pt states her work stressors are when there are lots of patients to take care of and she is unable to take a break.

Residency: Pt lives in a two story, four-bedroom home in the suburbs. Pt states it is a quit neighborhood with low crime rates. Pt states she has forced hot air. Pt states there are no environmental risks near her home. Stress and coping: Pt states her stressors in life include; caring for her 3 children, caring for her home, school and her job at times. Pt states her coping strategies include talking to friends and exercise. Finances: Pt states her finances are sufficient to maintain her home and family.