NRS434VN | Health Assessment of Well Older Adult
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.
Answer:
Assessing The Health Of An Elderly Adult
Demographics:
Initials: JH DOB: 17/7/1942 Marital Status: Wedded
Gender: Male Ethnicity/Culture: Caucasian
Health Insurance: Blue Chip Medicare Dental Insurance: _______________
Contemporary Health Condition:
JH believe that he is not sick though, he has some illness and also been hospitalized, some years ago. JH confesses that he had had regular exercises and has always checked his diets, all in the name of keeping fit and avoiding ill-health conditions. He also states that in the recent past, he has regularly visited a health-care provider and also went for cardiac rehab, on weekly basis. He further acknowledges his noble health that he has enjoyed in the previous year, during his recovery from the heart disease.
The Patient admits to having a
smoking history but he quitted two years ago. He also confesses that after quitting the smoking, he continued drinking little red wine, after every dinner. This particular Patient has recommendation for the treatment of his Blood-Pressure beside the OTC antacids and also he takes medications for the treatment of his allergic condition. He however fails to remember the names of the medicine he uses. The patient suffers hypersensitive conditions relating to dust and other particles that floats on the air. He admits confesses that whenever travelling by a car, he takes all safety measures and as a result, he has never been involved in a car accident. The patient agrees that he has not yet familiarized with the first aid or rather the Cardiopulmonary resuscitation (CPR) procedures.
Functional Health Patterns:
Action/Workouts:
The patient goes for cardiac rehab on weekly basis, rides on a reclining bike, does hand-related exercises and occasionally toils, all in the name of keeping fit. He spends his leisure time on skiing though, he has reduced the rate lately, as he recovered from the illness. He has recently enjoyed sailing during summers. The patient has a shoulder-pack prosthesis. This appeared after the ejection of his right-clavicle due to osteosarcoma which he experienced a couple of years ago.
Relaxation
The patient confesses to mostly have 6.5-7 sleep-hours per night. He says that he never naps at day-time. The patient says that he has never experienced sleepless night and as a result, he has never used any drug to improve his sleeping habits.
Heart/Respirational Status:
BP:120/60 Radiated Pulse: _________ Regularity: A-fib/flutter
Respirations: 18
He claims to not only have suffered chest-pain but also SNIFFLE however, not accompanied by coughs, swollen neck-veins, edema, cyanosis or varicosities.
Neuro-Muscular:
JH communicates in English and acknowledges his recurrent headaches experiences in the past. He has previously experienced attacks however, these attacks have been treated from the time of the occurrences. He says that, he has often suffered stability problems. He argues that, he has never experienced any issue related with vertigo, communication disorder, walking and visual problems, and has no memory-related issues.
Food/Diets/Metabolism:
Stature: 6’2.5” Weight 165 lbs.
JH feeds 3 times a day, no snacking. He doesn’t drink plenty of water. He doesn’t have damaged or missing teeth – from his recent dental examination. He hasn’t recently gained or lost weight.
Self-Perceptions
JH believes in fighting not to completely stop his skiing habits has no anger feelings, anxiety or despair but claims that his major weakness is the lack of patience. He has always dealt with it but the solution got always appear to be temporarily. His previous hospitalization brought about a substantial alteration in his life, as he claims. He keeps on wishing he was in a position to changes a thing to improve his life.
Cultural Assessment
The patient believes that his cultural background doesn’t affect the way he operates health-wise. Being a Caucasian, his social training is mainly based on English and Irish.
Sickness Perceptions And Believes
The patient believes that the major cause of illness to people is mainly the tension they get into. Whenever he gets ill, he prays, relaxes and then waits to get healed. Whenever the people he loves get ill, he prays on their behalf and takes cares for them.
Personal Affairs
He believes his household is great, having 4 grown-up children and a middle-aged companion. JH believes that all jobs can be done by anyone in the family. He believes that he and his wife disciplined their children as they were growing up. JH agrees that leading a good life full of gratitude is essential to anybody. He is an independent attorney and believes that capitals influence his life expectancy. Everyone in his family is a graduate.
Food And Diet Valuation
|
Break-fast |
Rations |
Lunch |
Goodies |
Dinner |
Snack |
|
Coffee (2-cups) Bran-muffin |
1 cup of water |
Chicken-stew Plus Fruit-Juice |
A cup of water |
Lasagna Red-wine |
|
|
Coffee (three cups) plus a bagel with peanut butter and jam |
Two cups of water |
|
|
|
|
His diet little fat contents and doesn’t take any supplements he is aware of it. He admits to consumption of chicken-meat, beef, and other type of meat on weekly basis. It is JH is advised to take plenty of water and to rise his vitamin consumption. His diets are often filled with carbohydrate and fresh. He doesn’t eat cruciferous vegetables and also high fiber foods. There is no adequacy in the intake of fresh foods
Prescriptions
JH takes 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, on a dily basis.
Metoprolol- he takes 150mg 2x/D po of Metoprolol for the treatment of high blood pressure in reducing chest pain and heart attacks prevention. Some side effects of this medication include Vertigo, fatigue, despair, swelling, indigestion or cold extremes.
Phenytoin- this is essential treating and prevention of seizures. From meds class, it’s reffered to as anticonvulsants. This is dangerous as it shakes the major brains activities. The main side-effect of phenytoin-related prescription is an unexpected rise in blood-sugar.
Therapeutic Accounts:
AVR since 2001, anxieties and illness triggered by sepsis, NPHER 12/29/11, Brigham and Williams Hospitalà AVR and CABGx2 on 1/5/12. s/o 5X lack of breathing sufficiency. Act sternal impurity through reop. Drainage, lasting A-fib/Flutter.
Atrial Fibrillation- also known as uneven-heartbeat. It’s triggered by jerking in the muscular-walls in the entrance of the heart, which disturbs the ventricles. It is a common occurrence in elderly people. Among the major signs of this disease is tremors, dizziness, SNIFFLE, angina, and apprehension.
Sepsis- this the cause of the severe fever the patient had suffered a couple of years ago. This is a contagion which is known to often affects the whole body of a patient. Its’ occurrence is experienced when blood-vessels widen. This can bring-about failure in multi-organ.
Conclusions
A patient named JH is a 74 year-old Caucasian male A&Ox3 in NAD. JH appears pleased with the lifestyle he enjoys and eager to share his health history to us. He expresses joy and happiness whenever he talks about his companion, household and the faith the family has in God. Despite the removal of his full-arm, JH has always strived to do carry-on with his hobbies, though at lower rate. JH goes for cardiac rehab on weekly basis, does some exercises to keep fit and always looking forward to improving on his diet. He wishes to ensure good health even in his elderly age and nothing can stop him.
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 RehabilitationÂ.Cardiac Rehabilitation. Retrieved March 4, 2014, from https://emedicine.medscape.com/article/319683-overview
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