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Please read the peers discussions and respond to them APA format with reference

Discussion 1

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In reviewing the data provided, there are several health risks that are associated with Mr. C’s obesity. His BMI is 46 which indicates morbid obesity. Morbid obesity is defined as having a BMI > than 30 (Copstead-Kirkhorn, & Banasik, 2014). Given his BMI of 46 along with a FBS of 146, suggests that Mr. C has diabetes. He admits to having HTN. He mentions that he tries to control his BP with a low sodium diet, however his BP remains high at 172/96 which suggest that he has uncontrolled HTN. His lipid panel is elevated, confirming high cholesterol and he has been diagnosed with sleep apnea.

Mr. C’s risk factors are as follows:

Diabetes

HTN

Hyperlipidemia

Sleep Apnea

Morbid Obesity

Based on this information, Mr. C is a candidate for bariatric surgery. He needs to take control of his health. Weight loss is a start and the key to controlling his other risk factors. Agreeing to have the surgery is the first step then there is a protocol that he will have to follow. All patients referred for bariatric surgery must undergo at least a year of specialist weight management services. The guidelines are that all appropriate non-surgical measures have been tried but the person has not achieved or maintained clinically beneficial weight loss and only after a person had received intensive treatment for weight loss (Schroeder, Garrison, & Johnson, 2011). With bariatric surgery, Mr. C. may have better control of his diabetes. “In a systematic review, metabolic surgery has been shown to be superior to medical treatment for short-term remission of type 2 diabetes and comorbidities” (Schroeder, Garrison, & Johnson, 2011). It is important to remember that bariatric surgery is not a weight loss technique, rather it is a tool that is used congruently with medical guidance, psychological support and lifestyle changes by Mr. C. to ensure positive outcomes.

Mr. C. has been diagnosed with peptic ulcer disease.

Another health issue of Mr. c. is his diagnosis of peptic ulcer disease. There is no mention of when his PUD was diagnosed or whether H.pylori was considered. “Most patients with PUD are treated successfully with cure of H pylori infection and/or avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs), along with the appropriate use of antisecretory therapy” (Anand & Katz, 2017). Mr. C’s current medication regime could be simplified by adding a PPI, such as Protonix, continuing with Zantac and Carafate and removing Mylanta (Mayo Clinic Staff, 2017).

Schedule:

7am- Carafate

8am- Breakfast and PPI such as Protonix

11am- Carafate

12pm- Lunch

5pm- Carafate

6pm- Dinner

10pm- snack

Bedtime -Zantac

Health perception and health management – Mr. C. is aware of his obesity and seems motivated to ask bariatric surgery and take control of his health. It is not clear whether he has attempted lifestyle changes or weight loss programs in the past.

Nutritional / Metabolic Pattern – These patterns are evident with Mr. C’s morbid obesity, uncontrolled HTN, undiagnosed diabetes and PUD. The DM and HTN have not been addressed medically since there are no medications prescribed that we know of. He would benefit with a nutritional consult to assist with meal planning and food choices.

Elimination- no information is given about his elimination patterns.

Activity / Exercise – Mr. C has a sedentary job at a catalog phone center. Given his weight I can assume that he has limited activity and exercise since there is no other information given.

Cognitive / Perceptual – Mr. C recognizes that his obesity is a problem. He shows motivation to ask about a surgical intervention to address this issue. He perceives his obesity as a medical concern and is worried about his health from his statement about his weight always having been a difficulty since childhood.

Sleep / Rest – He has documented sleep apnea, which contributes to poor quality of sleep.

Self – Perception / Self Concept- He perceives that he has a weight problem. This is supported by his statement that his weight has been a problem since childhood. He probably has a low self-esteem, but this needs further support.

Sexuality / Reproductive – no information given other than he is single.

Coping / Stress – He admits to gaining 100 pounds in the last 2-3 years. This could support the possibility that Mr. C uses food as a coping mechanism so these patterns need to be explored further.

Value / Belief – He is seeking information about a lifestyle change and bariatric surgery, so this supports the fact that he values his life. No information given about his beliefs.

What actual or potential problems can you identify? Describe at least five problems and provide the rationale for each.

Altered nutritional/metabolic pattern -Morbid obesity – BMI 46, HTN- BP 172/96, Hyperlipidemia – elevated lipid panel, Diabetes – FBS 146, PUD- cause unknown

Altered Sleep/ Rest -Diagnosed with sleep apnea. “Untreated, sleep apnea can cause high blood pressure and other cardiovascular disease, memory problems, weight gain” (American Sleep Apnea Association, n.d.).

Altered Health Perception/ Health Management Pattern- Non-compliance in weight management and low sodium diet, lack of follow-up in the past with weight management and HTN

Altered Self-Perception / Self Concept – “I have always been heavy, even as a child.”

Altered Coping/Stress Tolerance- Possible decompensation of coping mechanisms as evidenced by 100lb. weight gain

Reference

Anand, B., & Katz, J. (2017). Peptic Ulcer Disease. Retrieved from http://emedicine.medscape.com/article/181753-overv…

American Sleep Apnea Association. (n.d.). Sleep Apnea Information for Individuals. Retrieved from https://www.sleepapnea.org/learn/sleep-apnea/

Copstead-Kirkhorn, L., Banasik, J. L. (2014). Pathophysiology, 5th Edition. Chapter 42, p 846 [Pageburstl]. Retrieved from https://pageburstls.elsevier.com/#/books/978-1-455…

Katz, D., & Haslam, D. (2015). Is bariatric surgery the right approach to obesity? Retrieved from http://www.pharmaceutical-journal.com/opinion/comm…

Mayo Clinic Staff. (2017). Peptic ulcer. Retrieved from http://www.mayoclinic.org/diseases-conditions/pept…

National Heart Blood and Lung Institute. (n.d.). Calculate Your BMI – Standard BMI Calculator. Retrieved from https://www.nhlbi.nih.gov/health/educational/lose_…

Schroeder, R., Garrison, J. J., & Johnson, M. S. (2011). Treatment of Adult Obesity with Bariatric Surgery. Retrieved from http://www.aafp.org/afp/2011/1001/p805.html

Discussion 2

What health risks associated with obesity does Mr. C. have?

In Mr. C’s case scenario, the fasting blood sugar which is recorded at 146 mg/dL is higher than the normal levels of 70-100mg/dL (Smeltzer et al., 2010). This figure is indicative of diabetes. Likewise, blood pressure of 172/96 surpasses the normal range of 120/80 and thus indicative of hypertension. Also, the patient is at a risk of cardiovascular disorders such as coronary artery disease (CAD), stroke, congestive heart failure (CHF).

Is bariatric surgery an appropriate intervention? Why or why not?

Yes, I believe bariatric surgery is a more effective intervention for weight loss compared to non-surgical options. In fact, when combined with a comprehensive treatment plan, bariatric surgery may often act as an effective tool to provide you with long term weight-loss and help you increase your quality of health. Bariatric surgery has been shown to help improve or resolve many obesity-related conditions, such as type 2 diabetes, high blood pressure, heart disease, and more. Frequently, individuals who improve their weight find themselves taking less and less medications to treat their obesity-related conditions (ASMBS, 2017).

Assess each of Mr. C.’s functional health patterns using the information given (Hint: Functional health patterns include health-perception – health management, nutritional – metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception – self-concept, role-relationship, sexuality – reproductive, coping – stress tolerance).

Functional health patterns include:

Nutritional- In evaluating this healthcare pattern, obesity is identified as the major facing Mr. C healthcare condition. The condition is due to poor dietary, sedentary lifestyle. Nursing interventions are necessary to guide Mr. C to a proper self-care that would allow her to change her lifestyle and eating habits.

Activity and Exercise Pattern. Given the patient’s age, it’s clear that he is lacking physical and regular exercises.Physical activity or exercise can improve Mr. C’s health and reduce the risk of developing several diseases like type 2 diabetes, obesity and cardiovascular disease. Recommending physical activity and exercise can have immediate and long-term health benefits by improving the patient’s quality of life. A minimum of 30 minutes a day can allow Mr. C improved health benefits.

Sleep/Rest Pattern. The patient confirms that he has high blood pressure and sleep apnea. Exercising to lose weight could prevent the risk of blood pressure and improve his sleeping pattern.

Self-Perception-Self-Concept Pattern. This is more concentrated on an individual’sreflections or attitudes towards self, inclusive of self-image, and identity. Mr. C reports that he has always been heavy, even as a small child suggesting that he has accepted his condition. Research indicates that negative body image may increase the risk of obesity. Though previous research points to depression as a cause of obesity, researchers found no correlation between depression and obesity when they introduced body image into their research, suggesting body image may be a more significant factor in obesity risk. Counselling would be appropriate to help Mr. C cope with his condition (Villines Z., 2015).

What actual or potential problems can you identify? Describe at least five problems and provide the rationale for each.

  1. Hypertension which is evidenced by a blood pressure of 172/96 mmHg is known to alter with tissue perfusion and destruction of microvasculature. The patient seems to lack exercises and is currently suffering from obesity. These are the top factors and reasons identified to cause hypertension. Lack of exercise, as well as having a sedentary lifestyle, raises the risk of hypertension.
  2. Diabetes on the other hand is associated with destruction of microvasculature and activity intolerance (Smeltzer et al., 2010). Research on diabetes reports that obesity is the key player in the development of type 2 diabetes. A normal result for fasting blood glucose ranges from 70 – 100 mg/dL. According to criteria set by the American Diabetes Association, a higher than normal fasting blood sugar between 100 to 125 mg/dL (5.6 to 6.9 mmol/L) may indicate prediabetes. The patient’s Fasting Blood Glucose: 146/mg/Dl indicates increased risk of developing Type 2 diabetes.
  3. Sleep apnea alters the breathing functions thus prompting activity intolerance and predisposes the patient to heart diseases.
  4. Peptic ulcers are associated with altered nutrition less than body requirement due to altered absorption (Smeltzer et al., 2010). The patient is also at risk of altered fluid balance secondly to fluid and electrolyte loss due to diabetes.
  5. Lack of awareness: the patient report being heavy since he was young. Given that he is currently 31years old, he seems to have lacked avenues which promotes wellness and awareness. If Mr. C., was exposed to an environment that support physical exercise and proper eating habits he could have overcome his obesity problem. Lack of awarenss and education is therefore a problem of concern in his case.

References

ASMBS (2017). Benefits of Bariatric Surgery. Retrieved from https://asmbs.org/patients/benefits-of-bariatric-surgery

Fujimoto, A., Hoteya, S., Iizuka, T., Ogawa, O., Mitani, T., Kuroki, Y., … & Furuhata, T. (2013). Obesity and gastrointestinal diseases. Gastroenterology research and practice, 2013.

Smeltzer, S. C., Bare, B.G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner& Suddarth Textbook of medical surgical nursing (12th ed.). New York: Lippincott Williams and Wilkins.

Villines Z., (2015). Negative Body Image Linked to Obesity Among Adolescents. Retrieved from https://www.goodtherapy.org/blog/negative-body-ima…

Fujimoto, A., Hoteya, S., Iizuka, T., Ogawa, O., Mitani, T., Kuroki, Y., … & Furuhata, T. (2013). Obesity and gastrointestinal diseases. Gastroenterology research and practice, 2013.

Smeltzer, S. C., Bare, B.G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner& Suddarth Textbook of medical surgical nursing (12th ed.). New York: Lippincott Williams and Wilkins.

Villines Z., (2015). Negative Body Image Linked to Obesity Among Adolescents. Retrieved from https://www.goodtherapy.org/blog/negative-body-ima…

Discussion 3

  1. What health risks associated with obesity does Mr. C. have? Is bariatric surgery an appropriate intervention? Why or why not?

Mr. C is a 32 year old man whom is 5’6” and 296.5lbs. His BMI is 47.9 which puts him in the obese category. (“Calculate Your BMI – Standard BMI Calculator”). Mr. C’s blood pressure is high when checked at 172/96. Since he states he is attempting dietary change to fix his blood pressure the nurse should educate on sodium restriction and the patient should be offered to start a antihypertensive medication to help reduce risk of comorbidities due to hypertension. Before surgery Mr. C should have his blood pressure managed and check his A1C to determine if he is a diabetic before having any surgical intervention. Diabetes can affect a persons healing ability and could determine if he is getting the proper nutrients from his diet. This patient should also attempt diet and exercise to get as much weight off as possible before trying surgery.

  • “Efforts to lose weight with diet and exercise have been unsuccessful
  • Your body mass index (BMI) is 40 or higher
  • Your BMI is 35 or more and you have a serious weight-related health problem, such as type 2 diabetes, high blood pressure or severe sleep apnea
  • You’re a teenager who’s gone through puberty, your BMI is 35 or more, and you have serious obesity-related health problems, such as type 2 diabetes or severe sleep apnea” (“Gastric bypass surgery isn’t for everyone”, 2017, para 4)

Mr. C also has high cholesterol levels:

Total Cholesterol: 250mg/dL

“Total blood cholesterol level:

  • High risk: 240 mg/dL and above
  • Borderline high risk: 200-239 mg/dL
  • Desirable: Less than 200 mg/dL” (“Understanding Your Cholesterol Test Results”)

Triglycerides: 312 mg/dL

“Normal levels: Less than 150 milligrams per deciliter

  • Borderline high:150 to 199
      • High: 200 to 499
      • Very high: 500 or more” (“How to Lower Your Triglycerides”)

HDL: 30 mg/dL

HDL

40mg/dL or higher (“Cholesterol Levels: What You Need to Know”, 2018)

Due to these high numbers Mr. C should have a cardiology consult before going to surgery to check the status of his heart due to his high risk of having coronary artery disease. Mr. C should also have a psychiatric consult before getting surgery to determine if he is mentally stable enough to undergo surgery. New research is indicating that there is a high suicide risk for patients after receiving bariatric surgery. “For example, recent studies have identified an increased risk of suicide in people who have had weight-loss surgery. This risk is greatest in those who have attempted suicide in the past. More research is needed to understand whether changes related to the surgery itself play a role in increasing suicide risk.” (“Gastric bypass surgery isn’t for everyone”, 2017, para 8)

Mr. C should also have his thyroid checked to be sure there is not thyroid issue before surgery. Since Mr. C stated that he only remembers being overweight it is important to determine that there is not underlying causes to his weight problem.

2. Mr. C. has been diagnosed with peptic ulcer disease and the following medications have been ordered:

  1. Magnesium hydroxide/aluminum hydroxide (Mylanta) 15 mL PO 1 hour before bedtime and 3 hours after mealtime and at bedtime.
  1. Ranitidine (Zantac) 300 mg PO at bedtime.
  2. Sucralfate/Carafate 1 g or 10ml suspension (500mg / 5mL) 1 hour before meals and at bedtime.

The patient reports eating meals at 7 a.m., noon, and 6 p.m., and a bedtime snack at 10 p.m. Plan an administration schedule that will be most therapeutic and acceptable to the patient.

0600 Carafate

0700 breakfast

1000 Mylanta

1100 Carafate

1200 lunch

1500 mylanta

1700 carafate

1800 dinner

2100 mylanta and Carafate

1000 bedtime snack and zantac

3.Assess each of Mr. C.’s functional health patterns using the information given. (Hint: Functional health patterns include health-perception – health management, nutritional – metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception – self-concept, role-relationship, sexuality – reproductive, coping – stress tolerance.)

Health management: Mr. C is under the impression that he is managing his hypertension by having a sodium reduced diet, however, his blood pressure is indicating that his hypertension is not being managed. Mr. C requires education on diet and exercise and should be offered medication to help control his hypertension.

Health perception: Based off the information given it seems like Mr. C is under the impression that he is an overall healthy man with his weight being the only issue at hand. Mr. C needs a dietician to educate on proper foods to eat due to his cholesterol levels all being in high risk zone for heart disease.

Elimination/ sleep, rest/ sexuality/ and reproducing: from the information given there is not indication that Mr. C has problems with Elimination/ sleep, rest/ sexuality/ and reproducing. Although there is no indication that Mr. C has problems the nurse should question Mr. C to make sure that there are no issues before he gets surgery.

Coping: Mr. C should be assessed for mental health issues and learn about his coping skills. It seems since Mr. C has been heavy since he can remember he may be turning to food to cope. Getting psychiatric support could enlighten Mr. C as to why he eats to much and give him other means of coping during times of stress. This is very important prior to Mr. C surgery so that he does not hurt himself after surgery by consuming to much food.

Activity: Mr. C works at a telephone catalog center, it seems as if he may not be getting proper exercise that he requires to keep his body healthy. The nurse can suggest that during meal breaks that Mr. C takes a walk around the office and then can exercise at home or at the gym if he prefers.

4.What actual or potential problems can you identify? Describe at least five problems and provide the rationale for each.

Actual

Imbalanced nutrition more then body requirements: Mr. C reports that he only remembers being heavy even as a kid, it seems from the information given that Mr. C is consuming more calories then his body uses, especially with a job that he sits at a desk all day

Deficient knowledge: Mr. C is under the impression that he is managing his blood pressure by reducing sodium in his diet, however, the blood pressure taken during examination determines that he is not managing his blood pressure well at all. The nurse should educate Mr. C about the state of his blood pressure and educate on how to manage with medication, diet changes, and exercise.

Potential

Risk for anxiety: Patients that undergo surgery are often filled with anxiety wondering what is going to happen and afraid of the outcomes of surgery. Mr. C should be educated what to expect before, during, and after surgery. He should also be educated on potential risk so he can make the decision if surgery is right for him.

Risk for infection: after any surgery patients are at risk for infection of the surgical site. Mr. C should be educated before, during, and after surgery for signs and symptoms of infection and that he should call the doctor immediately. Signs and symptoms include: chills, fever, redness, drainage, pain, and foul smell from site.

Risk for ineffective coping: Since Mr. C only remembers being heavy he may be using food to cope with stress, after surgery this is not an option since this could cause harm to Mr. C. Mr. C should see a psychiatrist in order to find other coping methods, so he can adhere to instructions from the doctor post-surgery.

Reference

Calculate Your BMI – Standard BMI Calculator. (n.d.). Retrieved June 28, 2018, from https://www.nhlbi.nih.gov/health/educational/lose_…

Cholesterol Levels: What You Need to Know. (2018, March 22). Retrieved July 1, 2018, from https://medlineplus.gov/cholesterollevelswhatyoune…

Gastric bypass surgery isn’t for everyone. (2017, September 16). Retrieved July 1, 2018, from https://www.mayoclinic.org/healthy-lifestyle/weigh…

How to Lower Your Triglycerides. (n.d.). Retrieved July 1, 2018, from https://www.webmd.com/cholesterol-management/lower…

Understanding Your Cholesterol Test Results. (n.d.). Retrieved June 28, 2018, from https://www.webmd.com/cholesterol-management/chole…

Discussion 4

A person is considered obese when the BMI is 30 or higher. Mr. C is 1.72 m tall and weighs 134.5 kg. His BMI is therefore 45. Mr. C is morbidly obese.

There are many associated conditions that have been linked to obesity. Among them are hypertension, high cholesterol, diabetes, some cancers, heart disease and stroke, and sleep apnea. However, not every obese person will have these conditions.

A BMI over 35kg together with other co-morbidities, such as hypertension and sleep apnea, which Mr. C has, makes him an ideal candidate for bariatric surgery. According to Sarpel (2014), most overweight or obese people will only lose 10% of excess body weight, and relapse is common. Therefore, for the morbidly obese patient, with other co-morbidities, bariatric surgery is a good option. A comprehensive nutritional assessment and psychological intervention will be performed before a final decision since the patient needs further nutritional education after the surgery.

Mr. C’s functional health patterns will be assessed before his bariatric surgery to ensure he will benefit from the surgery. Bariatric surgery results in rapid weight loss that can be long-lasting. However, the procedure has also been associated with morbidity. Patient selection and education are paramount for the success of the surgery.

To start, Mr. C has demonstrated an interest in his health by inquiring about possible bariatric surgery. He understands it will be difficult to lose all the weight he needs just by dieting, given his lack of exercise and sedentary life. He also recognizes he does not sleep well due to his sleep apnea. The lack of good sleep could be a contributing factor to his obesity, which is probably a cause for his hypertension. Mr. C is a young single man and would like to change his lifestyle habits and achieve a normal weight that could bring his self-esteem back. He would need to see a psychologist that could help him deal with his self-esteem, his goals, the cause for his overeating since there is no history of any metabolic problems and assess his stress trigger points.

There are some potential problems after bariatric surgery, depending on the procedure done. There are two types of bariatric surgery: restrictive (caloric intake is decreased by creating a reduction in the stomach size) and malabsorptive (interrupting normal absorption of ingested calories). If restrictive, the patient runs the chance of the gastric remnant stretching to accommodate a larger volume of food, hence gaining the weight back. If malabsorptive, the risk is of not absorbing vitamins and minerals, since they do not stay in the bowel long enough to be absorbed. People also have the “dumping syndrome.” The most common surgery combines both restrictive and malabsorptive properties. It creates a small gastric pouch that is anastomosed to the down-stream small bowel. By doing this, the opportunity for caloric absorption is reduced. Patients will need lifelong nutritional supplementation since vitamins and minerals absorption is reduced.

Due to all the diet and nutrient intake issues, there is a need for a complete nutritional assessment and follow-up. The patient will have to re-learn to eat small frequent meals to be able to get all the calories needed.

Mr. C has also been diagnosed with peptic ulcer disease. Peptic ulcers can be due to different causes: H Pylori infection, drugs (e.g.NSAIDs), lifestyle factors, severe physiologic stress and hypersecretory states (although this is uncommon), and genetic factors. Our case study does not specify the cause for Mr. C’s peptic ulcer. We do not know if his ulcer is gastric or duodenal. If gastric, the symptoms would appear shortly after eating, and if duodenal, 2-3 after a meal.

The following medications were prescribed for his ulcer: (1) Mylanta 15 ml PO, one hour before bedtime, 3 hours after a meal, and at bedtime, (2) Zantac 300 mg PO at bedtime and (3) Carafate 1gm one hour before meals and at bedtime. According to Mr. C’s meals and bedtime schedule, he should be taking the medications as follow: (1) Mylanta – at 10 am, 3 pm, 9 pm, and 10 pm, (2) Zantac – at 10 pm, and (3) Carafate – at 6 am, 11 am, 5 pm and 10 pm.

After the surgery, the presence or absence of the peptic ulcers will have to be reassessed as well as all the medications. Is the ulcer still present, or was it removed during the gastric bypass (gastric ulcer) or was the ulcer removed from the duodenum?

Some nursing diagnosis will be:

1. Knowledge deficit related to new dietary guidelines as evidenced by smaller stomach with less space to hold food. He acknowledged having been overweight since childhood.

2. High risk for malnutrition related to bariatric surgery as evidenced by the reduced amount of time of nutrients in the bowel and opportunity for caloric absorption. He will need life-long nutrient supplementation.

3. Anxiety related to fear of the unknown as evidenced by not knowing what it will be like after the surgery.

4. Potential for ineffective coping mechanisms. Mr. C has been overweight since his childhood. He will have to learn new coping mechanisms to handle stressors.

5. Knowledge deficit related to undiagnosed diabetes. His fasting blood glucose of 146 is indicative of diabetes.

References

Sarpel, U. (2014). Bariatric surgery. In Surgery an introductory guide (pp. 123-126). [Adobe Digital Edition]. https://doi.org/10.1007/978-1-4939-0903-2

Discussion 5

Mr. C. have high cholesterol and fat (which indicates heart disease), high blood sugar (which may indicate diabetes), hypertension, and sleep apnea health risks associated with obesity. bariatric surgery may be an option, but it is not the first choose because Mr. C is only 32-year-old, he can try eating low sugar, low fat, low salt diet and exercise regularly to lose weight. If he follows the guideline to lose weight, I believe he will improve his health condition.

The administration schedule that will be most therapeutic and acceptable to Mr. C as follow.

· At 10 am, 3 pm, and 9 pm take Magnesium hydroxide/aluminum hydroxide (Mylanta) 15 mL PO

· At 10pm take Ranitidine (Zantac) 300 mg PO at bedtime.

· At 6am,11am, 5pm, and 9pm take Sucralfate/Carafate 1 g or 10ml suspension (500mg / 5mL)

According to the information given, Mr. C.’s functional health patterns are as follow. Health perception: Mr. C. always sees himself as heavy, even as a small child. Health management: He say he has sleep apnea and high blood pressure. No medication for this condition. He tries to control with salt to maintain health. he has three prescripted medication for her peptic ulcer disease. nutritional – metabolic pattern: Mr. C have three meal and one snack, it seems over nutrition. He does not have metabolic problem. His height is 68 inches; Weight is 134.5 kg, and his BMI is 45. He is obese. elimination, activity-exercise: this information could not find in the data. Sleep-rest: he says he has sleep apnea. I believe this problem may cause him without good sleep. Cognitive-perceptual: the data has not showing any sensory deficits and any disease that affects his mental functions. Mr. C express himself clearly and logically. Self-perception and self-concept: he seems not satisfy with his appearance by saying he has always been heavy, even as a small child. No data can find about role-relationship and sexuality – reproductive. Coping – stress tolerance: no clearly mention in this case scenario. However, he is seeking the bariatric surgery for his obesity, do not see he interest to change lifestyle. So, he seems like to use outside source to solve the problem, more than try inner effort.

The actual or potential problems are identified as follow: (according to Ralph and Taylor (2005), the nursing diagnosis as follow.)

1. Ineffective Breathing Pattern related to Inspiration and/or expiration that does not provide adequate ventilation. (rationale: Mr. C says he has sleep apnea, and his respiration rate is 26, and his is obesity (BMI is 45.)

2. Imbalanced Nutrition related to more than body requirements (rationale: he eats three meals and one snack a day. his BMI is 45. He is obese)

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