Question

In this assignment, you will be completing a health assessment on an older adult. To complete this assignment, do the following: Perform a health history on an older adult. Students who do not work in an acute setting may "practice" these skills with a patient, community member, neighbor, friend, colleague, or loved one. (If an older individual is not available, you may choose a younger individual). Complete a physical examination of the client using the "Health History and Examination" assignment resource. Use the "Functional Health Pattern Assessment" resource as a guideline to assist you in completing the template. Document findings of complete physical examination in Situation-Background-Assessment-Recommendation (SBAR) format. Refer to the sample SBAR Template located on the National Nurse Leadership Council website at https://www.ihs.gov/nnlc/includes/themes/newihstheme/display_objects/documents/resources/SBARTEMPLATE.pdf as a guide. Document the findings of the physical examination in the assessment worksheet. Using the "Health History and Examination" assignment resource, provide the physical examination findings summary with planned interventions for the client. Include any community services in the interventions. APA format is not required, but solid academic writing is expected.

Answer 1

HEALTH ASSESSMENT WELL OLDER ADULT

DEMOGRAPHICS:

Initials: JH                  DOB: 10/8/1939                     Marital Status: Married

Gender: Male                         Ethnicity/Culture: Caucasian

Health Insurance: Blue Chip Medicare           Dental Insurance:_______________

CURRENT HEALTH STATUS:

JH considers himself to be a somewhat health person besides his illness and hospitalization 2 years ago. To stay healthy, JH admits to exercising regularly and being aware of his diet. He admits to visiting a health care provider regularly and attends cardiac rehab twice per week. JH admits that his health has been very good over the past year as he continues to recover from his heart disease. In early 2012, he had been hospitalized for two months with an infection around his heart. Patient admits to smoking in the past but quit two years ago. He continues to drink a couple glasses of red wine at dinner every day. Patient takes a prescription medication for his Blood Pressure along with OTC antacids and allergy medications but does not remember the names. JH is allergic to pollen, walnuts, dust and mold. He admits to being UTD on all medications including influenza, shingles, hepB and pneumococcal. Patient wears his seat belt every time he is in the care and has never had any accidents nor been involved in one. He denies knowing first aid/CPR.

FUNCTIONAL HEALTH PATTERNS:

ACTIVITY/EXERCISE:

JH attends cardiac rehab twice a week, exercising on the recumbent bike, hand weights and sometimes the treadmill. He does not like using the treadmill. His leisure activates used to include skiing but since his hospitalization he has slowed down on this activity. He now enjoys sailing in the summertime. JH has shoulder pad prosthesis since the amputation of his right clavicle/ scapula for osteosarcoma in 1962. He denies needing a cane, walker or wheelchair.

SLEEP/REST :

JH admits to sleeping 6.5-7 hours per night and wakes up feeling rested. He denies napping during the day. He retires at 9:30pm and awakens at 4:45am. He denies any problems with sleeplessness and the used of sleep aids.

CARDIOVASCULAR/RESPIRATORY:

BP:120/60                   Radial Pulse:_________       Rhythm: A-fib/flutter

Respirations: 18

JH admits to chest pain and SOB. He denies cough, distended neck veins, edema, cyanosis and varicosities.

NEUROMUSCULAR/COGNITION:

JH speaks English. He claims he used to have bad migraines but doesn’t anymore. He has had 2-3 seizures a couple years ago but has been sense treated. Patient admits to having balance problems in the past. He wears glasses for reading. JH denies problems with dizziness, speech impediment, walking and visual problems. He does not use a hearing aid. UTA date of last hearing or eye exam. He denies any problem with memory.

NUTRITIONAL/METABOLIC:

Height: 6’2.5” Weight 165 lbs

            JH eats three full meals a day and denies snacking. He admits to not drinking enough water. He does not have dentures but has crowns. His last dental exam was a couple months ago. He denies weight loss and weight gain. JH is allergic to walnuts. He denies GI bleeding, difficulty swallowing, nausea, vomiting, anorexia and bulimia.

SELF-PERCEPTIONS/COPING/

JH’s friends would describe him as friendly, positive and sometimes funny. His source of strength and hope comes from God and his family and friends. He attends church at least once a week but often times multiple times per week.

PH admits that his health problems have affected his skiing but he has not stopped completely. He denies feelings of anger, fear, anxiety and depression but says the biggest negativity in his life is his impatience. He deals with this but just brushing it off and occasionally swearing. The only significant loss/change in this life was his hospitalization two years ago. If he could changes one thing to improve his quality of life it would be to be more generous.

CULTURAL ASSESSMENT

Patient denies his cultural background affecting his health care needs. He is Caucasian with his cultural background being English and Irish. His family shows they care by giving hugs and kisses.

ILLNESS BELIEFS AND CUSTOMS

JH said that people become ill when they are ill or when there is a lot of tension. When he is sick, he likes to pray, relax and tries to be patient, When his loved ones are sick he prays for them, cares for them and is there for them.

INTERPERSONAL RELATIONS

JH defines his family as terrific. He has four adult kids and a wife of 47 years. He denies specific duties for men women and children in a family. Growing up both him and his wife disciplined the children but now they live alone and take care of themselves and their families. JH admits that the most important aspect of life is leading a good life full of gratitude. There are no topics not discussed in their household. In his home they only speak English. JH is a self-employed attorney. He admits to finances influencing his life. He graduated form law school. His wife and three of his children graduated from college one having his doctorate.

NUTRITIONAL ASSESSMENT

Breakfast	Snack	Lunch	Snack	Dinner	Snack
Coffee (2cups) Bran muffin	1 cup of water	Chicken stew Fruit Juice	1 cup of water	Lasagna Red wine
Coffee (3cups) Everything bagel with peanut butter and jelly	2 cups of water

Patient does not have a high fat intake and does not take any vitamin supplements. He monitors his diet and admits to not eating enough fruits and vegetables. He admits to eating chicken, meat and fish each twice per week. JH recognizes that he does not drink enough water. He denies snacking during the day. It is recommended that JH drinks more water and try to increase his fruit and vegetable intake. He is eating an adequate amount of carbs and meat. All four food groups are represented. Cruciferous vegetables are not eaten, high fiber foods are not present. There is not a adequate intake of water and fresh foods do not make up most of his diet. Fish and chicken are eaten more then beef.

MEDICATIONS:

The medications taken by JH daily include Phenytoin (Dilantin) 20mg 2xD po, Metoprolol 150mg 2xD po, Warfarin INR 1xD po, Pepcid 20mg 1xD po, Singulair 10mg1xD po and Claritin 10mg 1xD po.

Metoprolol- JH is currently taking 150mg 2x/D po of Metoprolol. This medication is used to treat high blood pressure. This is also used to reduce chest pain and prevent heart attacks. This medication is considered a beta-blocker. Some side effects of this medication include Dizziness, tiredness, depression bloating, heartburn or cold extremities. JH is taking this medication to reduce angina and maintain a healthy blood pressure (Metoprolol).
Phenytoin- This is a medication used to treat and prevent seizures. This is in a class of meds known as anticonvulsants, which affect the electrical activity in the brain. One major side affect from this medication is a sudden increase in blood sugar.   Some other side affects of this medication include difficulty falling or staying asleep. Abnormal, uncontrollable eye and body movements, loss of coordination, slurred speech and overgrowth of gums. JH is taking this medication to prevent the reoccurrence of seizures that he suffered in the past (Phenytoin)

MEDICAL HISTORY:

            AVR from 2001, chills and fever caused by sepsis, NPHER 12/29/11, Brigham and Williams Hospitalà AVR and CABGx2 on 1/5/12. s/o 5X complicated respirations insufficient. Sub sternal infection with reop. Drainage, chronic A-fib/Flutter.

Atrial Fibrillation- also known as a-fib is another term for irregular heartbeat. This is caused by twitching in the muscle walls of the atrium of the heart, which therefore affect the ventricles of the heart. This can be either constant or persistent. This is common in older adults. Symptoms of this disease medical condition include palpitations, light-headedness, SOB, angina and anxiety.    This can be treated with medication (Atrial- Fibrillation).

Sepsis- JH had fevers due to sepsis in late 2011. Sepsis is a severe infection that affects the entire body. This occurs when blood vessels dilate and this can result in multi organ failure. Patients most at risk for this disease are those who are immunocompromised. The most common symptoms of this disease include hyperventilation, chills, shaking, decreased urine output and weak pulse (Sepsis).

CONCLUSION:

JH is a 74 y.o Caucasian male A&Ox3 in NAD. He seems very satisfied with his life and was excited to talk with us. He smiled constantly when talking about his family, his wife of 47 years and his faith in God. His full arm amputation has not held him back from doing things that he loves. He attends cardiac rehab faithfully and he is aware that he needs to improve upon his diet. He wants to continue maintaining his health and improve upon his life through his older adult years.

“Current cardiac care has already reduced early acute coronary mortality so much so that further exercise training, as an "isolated" intervention, may not be able to cause significant reduction in the morbidity and mortality.[2] Nonetheless, exercise training has the potential to act as a catalyst for promoting other aspects of rehabilitation, including risk factor modification through therapeutic lifestyle changes (TLC) and optimization of psychosocial support. Therefore, the outcome measures of cardiac rehabilitation now include improvement in quality of life (QOL), such as the patient's perception of physical improvement, satisfaction with risk factor alteration, psychosocial adjustments in interpersonal roles, and potential for advancement at work commensurate with the patient's skills”(Singh,V)

The above article from Medscape shows the positive outcomes of those who attend cardiac rehab and how it improves their lifestyles and health.

University:

Nursing 234 * Practicum in Foundations of Nursing with the Older Adult

Direct Study of an Well Older Adult / Client

Student Name:

Client Nursing Diagnosis	Client Outcomes / Goal	Nursing Intervention	Scientific Rationale for Nursing Interventions	Evaluation of Outcome & Revision Suggestions
JH needs to improve his diet but upping his fruit and vegetable intake along as meet his adequate water intake. 3/4/14	The client should aim to eat 2 cups of fruit and 2 cups of vegetables per day for 30 days. 3/3/14	1. Have the patient record his daily intake of fruits and vegetables. 2. Have his family join him in eating more fruits and vegetables. 3. Encourage him to help cook meal and select the fruits and vegetables he will eat.	1. To able to monitor that he is eating his the right amount of fruits and vegetables. 2. To encourage him to increase his intake by eating more themselves. 3. By preparing the food the way he likes them and choosing what he gets to eat, he will be more apt to eat them.	Target Date 3/3/14

References:

Ackley, B.J. &Ladwig, G. B. (2011). Nursing diagnosis handbook (9th ed.). St Louis, Missouri: Mosby Atrial Fibrillation-Find a Doctor, Symptom Checker, Conditions, Medications, Procedures and Hospitals - iTriageHealth.com. (n.d.). Find a Doctor, Symptom Checker, Conditions, Medications, Procedures and Hospitals - iTriageHealth.com. Retrieved March 4, 2014, from https://www.itriagehealth.com/conditions/atrial-fibrillation-irregular-heart-rate-67

Medical Record. (2014). Metroprolol- Find a Doctor, Symptom Checker, Conditions, Medications, Procedures and Hospitals - iTriageHealth.com. (n.d.). Find a Doctor, Symptom Checker, Conditions, Medications, Procedures and Hospitals - iTriageHealth.com. Retrieved March 4, 2014, from https://www.itriagehealth.com/medications/metoprolol-747

Phenytoin-Find a Doctor, Symptom Checker, Conditions, Medications, Procedures and Hospitals - iTriageHealth.com. (n.d.). Find a Doctor, Symptom Checker, Conditions, Medications, Procedures and Hospitals - iTriageHealth.com. Retrieved March 4, 2014, from https://www.itriagehealth.com/medications/phenytoin-168

Potter, P. A., Potter, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing (8th ed. St. Louis, Missouri: ELSEVIER Mosby.

Sepsis-Find a Doctor, Symptom Checker, Conditions, Medications, Procedures and Hospitals - iTriageHealth.com. (n.d.). Find a Doctor, Symptom Checker, Conditions, Medications, Procedures and Hospitals - iTriageHealth.com. Retrieved March 4, 2014, from https://www.itriagehealth.com/conditions/sepsis-severe-infection-687

Singh, V. (2013, October 18). Cardiac Rehabilitation .Cardiac Rehabilitation. Retrieved March 4, 2014, from http://emedicine.medscape.com/article/319683-overview