Question

CASE STUDY #6 FOR WEEK 2 NR224

Miss SP is a 75 year old female who comes to your ER saying she is so tired she cannot care for herself and wonders what she should do. She has always been independent and able to care for herself and her sister who is 80 years old. They were both school teacher and retired about 20 years ago. They did a lot of traveling and have just returned from a trip through Russia via the Viking cruise on the river from Moscow to St. Petersburg. She thought the trip was exhausting which was when her sister started nagging her to get checked. Today she insisted that she come in to the ER as their primary care provider was not able to see her for 2 weeks. She has a PMH of hypertension and hyperlipidemia and might have had a minor heart attack about 10 years ago. She does note that if she rests for an hour or so she again has some energy but it does not last long. Denies chest pain or shortness of breath. You find when you ask more questions that her sister is having some issues with her memory.

In doing your assessment what further history do you need, what exam would you want to do and what would be an appropriate nursing diagnosis. When you have decided on the nursing diagnosis, come up with a plan, a SMART goal and implementation and how would you evaluate it.

Answer 1

Nursing diagnosis

1. Activities intolerance related to functional changes due to aging process as evidence by weakness.

SMART goal

- The patient will be able to maintain the normal activities by reducing the weakness

Intervention

- assess the condition of the patient

- assist the patient while doing daily living activities.

- Provide adequate rest to the patient

- provide high calorie diet to increase energy

- Encourage the patient to do activities slowly

- Encourage the patient to practice energy conservation techniques while doing activities

Evaluation

- The patient able to performed daily activities and verbally evidence of reduce weakness

2. risk of fall related to weakness and increase aging process.

SMART goal

- The patient will be free from risk of fall

Intervention

- Assess the patient activities level

- Provide the equipment like walker or cane, so that the patient can walk properly

- prevent wet floor

- attach supportive bar in the wall of the room and the washroom

- assist the patient while doing activities

Evaluation

The patient is free from risk of falls by maintaining safety measures.