lOMoARcPSD|5734770
lOMoARcPSD|5734770
Nursing Care Plan: Osteoporosis
Name
Institution
Professor
Course
Date
, lOMoARcPSD|5734770
2
Head to Toe Assessment
Patient: The patient is a 49 years old woman who presents with back pain and swollen upper
thigh/hip.
CC: The patient complains of back pain, swollen hip, and significant weight loss in the last two
and a half months. The Caucasian female visits the office with concerns over prolonged back
pain, significant weight loss, and stopped posture. She reports that mild pain started three
months ago but became more severe in the last two weeks. Her upper leg was hit by a chair one
day ago, causing swelling. She expected the pain and swelling to go away, but it persisted,
hence seeking medical care. The patient also reports that she has had fractures two times in the
last year, and mild traumas caused all. She says that the pain is aggravated by minimal
activities such as walking short distances, bending, and carrying out daily house chores with no
relieving factors. She rates the pain as 8/10. She reports that she has also lost significant weight
despite eating the same food she eats without engaging in physical activity. The patient reports
she is currently unable to perform some ADLs due to pain and limited mobility. However, the
patient denies loss of height, chills, headache, and tingling of feet. She is also not on
medication but took Tylenol for pain before she decided to come for help.
PMH: Pneumonia during childhood, bone fractures
Surgical History: myomectomy six years ago
Allergy: No known allergies
Immunizations: The patient took a flu shot in 2019.
Personal History: Married with two children and live together as a family in their apartment.
The patient denies smoking or alcohol use.
Family History: Father (deceased) had diabetes and hypertension. The mother has osteoporosis.
Review of Systems: Subjective
General: The patient denies headache, bruises, and chills but reports fever and is concerned
about weight loss.
, lOMoARcPSD|5734770
3
HEENT: Head- the patient denies headaches, hair loss, or notable masses. Ears- the patient
reports no changes in hearing, ear discharge, or ringing in years. Eyes: The patient denies blurry
vision but uses eyeglasses for reading. Nose-the patient denies congestion, nose bleeds, and
dryness. Mouth: The patient denies bleeding gums, decayed or missing teeth, odors, and
dryness. Neck: the patient denies swelling and enlarged lymph nodes, pain or difficulty
swallowing, and stiffness. Throat: patient denies sore throat, erythema
Cardiovascular: the patient denies chest pains or discomforts, fast/slow heart rates, and cold
feet/hands. The patient reports swelling of the lower limb.
Respiratory: The patient denies chest tightness, wheezing, pain, consistent coughs, and
breathing difficulties.
Skin: The patient denies discoloration, bruising, lumps, and open wounds
Gastrointestinal: The patient denies constipation, abdominal pain/discomfort, heartburn, nausea,
bowel movement changes, guarding and tenderness, and distension.
Musculoskeletal: The patient denies back tenderness, stiffness, and joint swelling but reports
back pain, limited ROM due to swelling at the hip area, and inability to bear weights.
Neurological: The patient reports stooped posture and deny memory loss, tremors, severe
headaches, and loss of consciousness.
Endocrine: The patient denies swollen glands, excessive sweating, thyroid problems, and reports
weight loss.
ROS: Objective Data
Vitals: T: 98.6F, BP: 125/82, Pulse: 85, W: 132, H: 5’4”, RR: 18
General: The patient appears distressed but alert and oriented to place and time. She shows
limited movement. Her speech is soft with a clear tone.
HEENT: Head: size and symmetry are normal on inspection, and hair is clean and fine. The
scalp has no lesions and no tenderness noted on palpation. Eyes: has high eye acuity, pupils
react to light, they are equal and round. The sclera is normal, white, and moist. No discharge
was noted. The patient wears glasses. Ear: External year position and shape is normal on
inspection.
lOMoARcPSD|5734770
Nursing Care Plan: Osteoporosis
Name
Institution
Professor
Course
Date
, lOMoARcPSD|5734770
2
Head to Toe Assessment
Patient: The patient is a 49 years old woman who presents with back pain and swollen upper
thigh/hip.
CC: The patient complains of back pain, swollen hip, and significant weight loss in the last two
and a half months. The Caucasian female visits the office with concerns over prolonged back
pain, significant weight loss, and stopped posture. She reports that mild pain started three
months ago but became more severe in the last two weeks. Her upper leg was hit by a chair one
day ago, causing swelling. She expected the pain and swelling to go away, but it persisted,
hence seeking medical care. The patient also reports that she has had fractures two times in the
last year, and mild traumas caused all. She says that the pain is aggravated by minimal
activities such as walking short distances, bending, and carrying out daily house chores with no
relieving factors. She rates the pain as 8/10. She reports that she has also lost significant weight
despite eating the same food she eats without engaging in physical activity. The patient reports
she is currently unable to perform some ADLs due to pain and limited mobility. However, the
patient denies loss of height, chills, headache, and tingling of feet. She is also not on
medication but took Tylenol for pain before she decided to come for help.
PMH: Pneumonia during childhood, bone fractures
Surgical History: myomectomy six years ago
Allergy: No known allergies
Immunizations: The patient took a flu shot in 2019.
Personal History: Married with two children and live together as a family in their apartment.
The patient denies smoking or alcohol use.
Family History: Father (deceased) had diabetes and hypertension. The mother has osteoporosis.
Review of Systems: Subjective
General: The patient denies headache, bruises, and chills but reports fever and is concerned
about weight loss.
, lOMoARcPSD|5734770
3
HEENT: Head- the patient denies headaches, hair loss, or notable masses. Ears- the patient
reports no changes in hearing, ear discharge, or ringing in years. Eyes: The patient denies blurry
vision but uses eyeglasses for reading. Nose-the patient denies congestion, nose bleeds, and
dryness. Mouth: The patient denies bleeding gums, decayed or missing teeth, odors, and
dryness. Neck: the patient denies swelling and enlarged lymph nodes, pain or difficulty
swallowing, and stiffness. Throat: patient denies sore throat, erythema
Cardiovascular: the patient denies chest pains or discomforts, fast/slow heart rates, and cold
feet/hands. The patient reports swelling of the lower limb.
Respiratory: The patient denies chest tightness, wheezing, pain, consistent coughs, and
breathing difficulties.
Skin: The patient denies discoloration, bruising, lumps, and open wounds
Gastrointestinal: The patient denies constipation, abdominal pain/discomfort, heartburn, nausea,
bowel movement changes, guarding and tenderness, and distension.
Musculoskeletal: The patient denies back tenderness, stiffness, and joint swelling but reports
back pain, limited ROM due to swelling at the hip area, and inability to bear weights.
Neurological: The patient reports stooped posture and deny memory loss, tremors, severe
headaches, and loss of consciousness.
Endocrine: The patient denies swollen glands, excessive sweating, thyroid problems, and reports
weight loss.
ROS: Objective Data
Vitals: T: 98.6F, BP: 125/82, Pulse: 85, W: 132, H: 5’4”, RR: 18
General: The patient appears distressed but alert and oriented to place and time. She shows
limited movement. Her speech is soft with a clear tone.
HEENT: Head: size and symmetry are normal on inspection, and hair is clean and fine. The
scalp has no lesions and no tenderness noted on palpation. Eyes: has high eye acuity, pupils
react to light, they are equal and round. The sclera is normal, white, and moist. No discharge
was noted. The patient wears glasses. Ear: External year position and shape is normal on
inspection.
