Gerontology Project

Name: Onipha Tappin Date: 1st Aug, 2013 Teacher: Sis Smith Class: Group 16

Table of contents

Introduction.. Biographical Data.... Subjective Data. Review of Systems. Head to Toe Assessment Social Support System... Care Plan...

Introduction

In this project you will find the assessment done on my choice of gerontology client. The home chosen for the setting of this project was the Bishop John E. Knight home for the elderly.

Assessment

Biographical Data
Name: Clara J King Sex: Female D.O.B: 12/09/31 Age: 81 years Address: Clare Hall Village Contact #: Tel: 560-3695

Country of Birth: Antigua Nationality: Antiguan Religion: Methodist Race: Black Place of Employment: None Marital Status: Married (spouse deceased) Next of Kin: Velvet Charles Address: Glanville Village Medical Insurance: No Family physician: Dr Stevens The source of information is reliable Informant: Clara King Relationship: Friend Tel: 720-1003

Chief Complaint No complaints

History of Present Illness

Hypertension

Past Medical History

Childhood Illness: History of Measles. No history of mumps, mumps, chickenpox, rubella, frequent ear infections, frequent streptococcal infections or sore throats, rheumatic fever, scarlet fever, pertussis, or asthma.

Accidents/Injuries: No accidents or injuries

Chronic Illnesses: Hypertension

Obstetric History: Gravida 2 para 2

Immunization:

All childhood vaccinations received measles, mumps, rubella, chickenpox, hepatitis B, diphtheria, polio, Tetanus 2nd booster.

Hospitalizations: Surgical removal of Fibroids in the 1970s at age 43, hospitalized for two weeks at the Holberton hospital.

Last Examinations: Every Sunday.

Allergies: No known allergies

Current medications: Zesteretic 20mg daily, ASA 81mg daily.

Current health status

General health is OK. No changes in appetite or weight. Able to perform ADLs without difficulty. No history of weakness, unexplained fevers, or unusual symptoms.

Family History
Eugenia is the 2nd child out of 3, parents were married, mother had hypertension and sister also. Her husband died from complications of hypertension

Psychosocial History
Self-concept- Completed education to the 7th grade of secondary school then stayed to help care for the family. Believes in god and is very religious. Believes self to be loving, kind, Lifestyle- No smoking. Drinks wine on special occasions.

Diet-Eats breakfast but sometimes skip lunch due to lack of appetite but eats dinner, believes nutritional status is adequate. Gets approximately 12 hours of sleep. Spends most of the day sleeping and watching television. Exercise- She exercises every morning. Social- Describes life as happy and contented. Has a good relationship with family and other residents.

Review of Systems
Neurological: No history of fainting, seizures, loss of consciousness, head injuries, changes in cognition or memory, hallucinations, disorientation, speech problems, sensory disorientation such as numbness, tingling or loss of sensations, motor problems, problems with gait, balance or coordination. No impact on ADLs.

Respiratory: No history of breathing problems, cough, bloody sputum, SOB with activity, wheezing, pneumonia, bronchitis or tuberculosis. Cardiovascular: History of hypertension. No history of chest pain, palpitations, murmurs, skipped beats, awakening at night with SOB, dizzy spells, cold hand or feet, colour changes in hands and feet, pain in the legs while walking, swelling of the extremities, hair loss on legs, poor wound healing. Has never done an EKG.

Gastrointestinal: No history, indigestion, change in appetite, heartburn, nausea, vomiting, liver or gallbladder disease, jaundices, changes in bowel patterns; colour of stool, constipation or diarrhoea, hemorroids, weight changes (loss or gain), use of laxatives and acids.

Genitourinary: No history of pain on urination, burning, urgency, dribbling, incontinence, hesitancy, changes in urine stream or colour, no history of urinary tract infections, kidney infections, kidney disease, kidney stones, or frequent urination at night.

Musculoskeletal: No history of fractures, history of sprains, muscle cramps, pain, weakness, noise with movement, spinal deformities, low back pain, loss of height, osteoporosis, degenerative joint disease, or rheumatoid arthritis.

Skin: No history of rashes, lumps, sores, mild dryness, no colour changes. No history of changes in hair or nail.

Head/Neck: No history of unusual headaches, head injury or surgery, dizziness, loss of consciousness or fainting. No history of stiff neck, injury or surgery, pain with movement of head and neck, swollen glands, nodes or masses.

Eye: No history of blurred vision, vision loss, colour or depth perception.

Ears: No history of difficulty hearing, sensitivity to sounds, ear pain, drainage, vertigo, ear infections, ringing, fullness in the ears.

Nose: No history of nosebleeds, use of recreational drugs, allergies, broken nose, difficulty breathing through the nose, sneezing.

Mouth/Throat: No history of sore throats, streptococcal infections, mouth sores, oral herpes, difficulty chewing or swallowing, changes in sense of taste.

Breast: No history of masses, lumps, discharge, pain, swelling, changes in breast or nipple, breast cancer, breast surgery.

Head-to-Toe Assessment

Height: 55 B/P: 110/70mmHg Pulse: 76 bpm

Weight: 170lbs Temp: 97F Resp: 20 bpm

General health survey: Eugenia Jones is a 81 year old black female, she articulates clearly, ambulates without difficulty.

Skin, Hair, Nails: skin, uniform in colour, warm, dry, intact, turgor good. Hair, normal distribution and texture, no lice or other inhabitants, mostly white and sheared. Nails, no clubbing, biting present, no discolorations. Nail beds pink and firm with prompt capillary refill. Wrinkles on face.

Head: Normocephalic, no lesions, lumps, scaling, parasites, or tenderness. Face, symmetric, no weakness, no involuntary movements.

Eyes: Glasses worn when reading. Visual fields adequate. Eye movement adequate. Sclera clear. Eye lashes and eye browns are white. Ears: Symmetrical with no deformities. Canals clear. Pinna, no mass, lesions, scaling, discharge, or tenderness on palpation. Whispered words equally heard.

Nose: Symmetrical. No deformities or tenderness on palpation. Nares patent. Mucosa pink, no lesions. Septum midline, no perforation. No sinus tenderness.

Mouth: Mucosa and gums pink, no lesions or bleeding. Slight yellowing to teeth noted, no cavities present, four incisors missing. Tongue symmetric, protrudes midline. Uvula rises midline. Gag reflex present. Dentures worn.

Neck: Symmetric, no masses, tenderness. Trachea midline. Thyroid nonpalpable, not tender. Neck supple with full ROM.

Spine and Back: Normal alignment of spine, no deformities noted. No tenderness on palpation.

Thorax and Lungs: Equal bilateral chest expansion. Breath sounds audible. Diaphragmatic excursion equal bilaterally. Lungs field clear with no adventitious sounds.

Breasts: Symmetric, no discharge or lesions. No masses or tenderness on palpation.

Heart: No pulsations, lifts or heaves. Heart sounds normal, no murmurs or thrills present.

Abdomen: Round, symmetric. Skin smooth with no lesions, scars or striae. Bowel sounds present, no bruits. Abdomen soft, no organomegaly.

Musculoskeletal: Colour distribution on extremities equal, no deformities or lesions. No tenderness. All peripheral pulses present and equal bilaterally. Full ROM present. No tenderness or weakness in joints. Muscle strength able to maintain flexion against resistance and without tenderness.

Neurologic: Alert and oriented to person place and time. Thought coherent. Remote and recent memories intact. Cranial nerves ii through xii intact. Sensory, pin prick, light touch intact. Able to identify objects. No atrophy, weakness or tremors. No gait abnormalities. Cerebellar, finger to nose smoothly intact.

Social support system

The client has a very good social system her friends visit regularly and her family visits during holidays. They aid in meeting all her economic and other needs.

Physical and psychological environment The physical and psychological environment is very structured and comforting. Everything is free from clutter so there is a reduced risk for injury. It is also filled with personal items that offer comfort. There is also a lot of stimuli available without it overloading the client.

Area of need for education

The area identified for need for education is the need for proper hypertension management. If this is not done properly it may lead to other health problems example stroke, heart attack and heart failure, vision problems and poor blood supplies to lower extremities. The reason this area was identified is because the client has fluctuating blood pressures. She also needs education on proper stress management as this causes her fluctuating blood pressures.

Assessment Elderly female client with difficulty managing hypertension

Nursing Diagnosis Knowledge deficit related to managing blood pressure evidence by clientsfluctuating blood pressures

Goal Client will be to adequately manage blood pressure

Interventions - Monitor blood pressure readings daily. This aids in noting elevation or depression of Bp.

Outcome Criteria - client able to adequately manage blood pressure

- Advise client to take prescribed medication ad directed at all times unless asked to stop by doctor. This aids In maintaining an adequate blood pressure level. - Keep a dated record of Blood pressure readings. This keeps a set record of blood pressure changes. - Assist client in finding ways to

manage stress. As stress causes an increase in blood pressure. - Encourage regular exercise approximately 30-40 minutes daily 3-4 times per week. This aids in both managing blood pressure and relieves stress. - encourage client to maintain a healthy weight. Excess weight increases risk for high blood pressure and cholesterol problems. -Advise client to decrease salt intake and foods high in fat and cholesterol. These cause a rise in blood pressure.

Assessment Elderly client with difficulty managing stress

Nursing Diagnosis Impaired coping mechanism related to stress evidenced by clients fluctuating blood pressures.

Goal Client will have an adequate coping mechanism to manage stress with health teaching

Interventions Encourage the client to think positively when under stressful situations as this help to calm her thus relieving stress.

Outcome Criteria Client is adequately able to manage stress

Encourage the client to try relaxing exercises such as meditating reading etc. as this aids to relieve stress.

Encourage the client to seek spiritual guidance(i f she is spiritual) a this offers guidance and relieves stress

Managing Hypertension Monitor blood pressure regularly. This notes elevation or depression in blood pressure. Keep a dated record of blood pressure readings. This aids in better managing blood pressure and also aids clinician in noting changes in your blood pressure. Managing stress aids in managing your blood pressure. Stress increases you blood pressure. So practice activities that you find restful to aid in lowering your stress level thereby lowering your blood pressure. Limit alcohol or cease alcohol consumption. Get regular exercise approximately 30-40 minutes daily 3-4 times a week. This manages stress and maintains a healthy lifestyle. Decrease salt intake, read packages of food products. Take prescribe medication as ordered unless contraindicated by your doctor. Reduce intake of foods high in fat and cholesterol. Maintain a healthy weight. Excess weight increases for high blood pressure and cholesterol problems. Stop smoking. It damages blood vessels which is dangerous in person with high blood pressure.