Running head: BRADLEY GERONTOLOGY PROCESS PAPER1
Gerontology Process Paper
Erin Bradley
Kent State University at Stark
Client Profile
DH, a 93-year-old Caucasian female, was admitted to the facility with right lower leg cellulitis. Her secondary diagnoses include atrial fibrillation, hypothyroidism, osteoporosis, and glaucoma. DH is 62 inches tall and states that she weighs 108 pounds, or 49.09 kilograms. DH was previously employed by a printing company in Canton where she worked as an accountant for over 50 years. DH states that her husband had passed away several years ago and she had been living independently until only recently. Prior to entering the facility, she was abiding with her daughter’s family who lives near the Canton area. DH states that she is Protestant. She is allergic to aspirinand Dilaudid. DH is a Do Not Resuscitate-Comfort Care Arrest patient.
Past Medical & Surgical History
DH has a history of osteoporosis, which ultimately led to the pathologic fracture of the neck of her right femur and a total right hip arthroplasty in 2011. DH states that her fracture was the reason she began living with her daughter after she was discharged from the rehabilitation facility. DH has a history of hypothyroidism that she states is well maintained by her current regimen of thyroid hormones. She also stated that she was diagnosed with glaucoma in 2008 and is on a strict regimen of ophthalmic medication to alleviate symptoms. Lastly, DH has a history of paroxysmal atrial fibrillation that occurs randomly without any known cause.
Medical Diagnoses
CellulitisDefinition: “A skin infection that extends into the deeper dermis and subcutaneous tissues and causes deep, red erythema without sharp borders and that spreads widely through tissue spaces” (Black & Hawks, 2009, p. 1225).
Pathophysiology: Streptococcus pyogenes is usually the cause of this infection. Older patients may be at more risk for cellulitis with the presence of wounds or ulcers, malnutrition, steroid therapy, or a history of diabetes(Black and Hawks, 2009).
Signs and Symptoms: Skin may appear edematous, erythematous, nodular, and tender. Sometimes they organism that causes the skin infection can cause other manifestations, such as high fever, confusion, tachycardia, and hypotension (Black and Hawks, 2009).
Diagnosis: Wound specimen for culture and sensitivity testing is performed to determine the cause of infection and proper antibioticstreatment (Black and Hawks, 2009).
Treatment: IV and/or oral antibiotics that are effective against streptococci and S. aureus. Soaks can be used to reduce inflammation and edema (Black and Hawks, 2009).
Osteoporosis
Definition: A systemic skeletal disorder that leads to compromised bone strength and increased risk for skeletal fracture (Black and Hawks, 2009).
Pathophysiology: Fractures related to osteoporosis occur when the bone encounters weight greater than what it can sustain. Post-menopausal Caucasian women are at a higher risk for osteoporosis, but other factors such as medication us (corticosteroids, thyroid hormones, anticonvulsants, and furosemides) and underlying medical conditions, like anorexia nervosa, Cushing’s syndrome, and hyperparathyroidism, place patients at risk (Black and Hawks, 2009).
Signs and Symptoms: Shortened stature, kyphosis, and bone loss in the mandible leading to loss of teeth or poorly fitting dentures (Black and Hawks, 2009).
Diagnosis: Diagnosis of osteoporosis is generally made after a fracture has occurred. Bone mineral density (BMD), a value of bone density that is expected for a person’s age and gender, can be measured using full-table dual-energy x-ray absorptiometry (DXA) (Black and Hawks, 2009).
Treatment: Osteoporosis is preventable. Increasing calcium and Vitamin D intake as early as age 10 for females can help prevent osteoporosis. 1200 milligrams of calcium per day is recommended for patients above the age of 70. Weight-bearing exercise is also a good way to increase bone mass. (Black and Hawks, 2009).
Hypertension
Definition: “Persistent elevation of the systolic blood pressure (SBP) at a level of 140mm Hg or higher and diastolic blood pressure (DBP) at a level of 90mm Hg or higher” (Black & Hawks, 2009, p. 1290).
Pathophysiology: Because the cause of primary hypertension is not well known, hypertension without a cause is labeled accordingly (Tabloski, 2010). Secondary hypertension is related to problems that affect the kidneys, interfering with “sodium excretion, renal perfusion, or the renin-angiotensin-aldosterone mechanism, leading to an elevation in blood pressure over time” (Black & Hawks, 2009, p. 1293).
Signs and Symptoms: When left untreated, hypertension may cause headache, dizziness, fatigue, flushing, palpitations, visual changes, and nosebleed (Black and Hawks, 2009).
Diagnosis: A diagnosis of hypertension is made by taking two blood pressure readings while the patient is seated and at least two minutes apart. This must be completed after at least five minutes of rest (Black & Hawks, 2009). These readings must have an average of 140/90 or higher in order for hypertension to be diagnosed. Specific studies to diagnose hypertension include: complete blood count (CBC), urinalysis, chest x-ray, fasting blood glucose, serum levels of potassium and sodium, serum cholesterol, blood urea nitrogen (BUN), serum creatinine, and electrocardiogram (EKG) (Black & Hawks, 2009).
Treatment:Antihypertensive medications include ACE-inhibitors, diuretics, beta blockers, calcium channel blockers, vasodilators, and angiotensin receptor blockers. Lifestyle modifications such as weight reduction, sodium restrictions, dietary fat modification, exercise, alcohol restriction, caffeine restriction, relaxation techniques, smoking cessation, potassium supplementation, and pharmacologic interventions are stressed as well. (Black and Hawks, 2009).
Paroxysmal Atrial Fibrillation
Definition:Atrial fibrillation, or A Fib, is a supraventricular dysrhythmia that is characterized by rapid depolarization of the atria from a re-entrant pathway (Black & Hawks, 2009).
Pathophysiology: Impulses of 350 to 600 beats per minute may occur at random, not allowing the atrium to fully recover from one depolarization to the next. These chaotic impulses lead to ineffective atrial contraction, which in turn lead to a decrease in cardiac output by as much as 30% (Black & Hawks, 2009).
Signs and Symptoms: As cardiac output continues to decline, dyspnea, angina pectoris, heart failure, and shock may result (Black & Hawks, 2009).
Diagnosis: A pulse deficit between apical and radial pulses may be palpated. An electrocardiogram is preferred diagnostic test to reveal A Fib. Examination of the test reveals unidentifiable P waves and irregular ventricular rhythm (Black & Hawks, 2009).
Treatment: Anticoagulation, i.e. heparin or oral warfarin are started to reduce the risk of thromboembolism. Aspirin may be started for those patients who have a fall risk or a history of hemorrhage or gastrointestinal bleeding. Converting A Fib. Back to normal sinus rhythm can be achieved by cardioversion or medications. Diltiazem, verapamil, beta-blockers, or digoxin will control heart rate (Black & Hawks, 2009).
Glaucoma
Definition:“Glaucoma comprises a group of ocular disorders characterized by increased intraocular pressure, optic nerve atrophy, and visual field loss” (Black & Hawks, 2009, p. 1699).
Pathophysiology: Intraocular pressure is determined by the amount of humor production in the ciliary body and the resistance to outflow of aqueous humor from the eye. An increase in intraocular pressure can occur from an obstruction of the flow of aqueous humor or a hyperproduction of aqueous humor. As the pressure increases, blood supply to the optic nerve and retina are inhibited and tissues within the eye become ischemic (Black & Hawks, 2009).
Signs and Symptoms:Severe eye pain, vision loss and blurred vision, rainbow colored halos around lights, nausea and vomiting may occur (Black & Hawks, 2009).
Diagnosis: Ophthalmoscope examination may show atrophy or cupping of the optic nerve. Visual field examination is tested to discover the amount of vision loss (Black & Hawks, 2009).
Treatment: Increasing the aqueous humor flow can reduce intraocular pressure. This can be achieved by constricting the pupils using epinephrine or topical miotics. Topical beta-blockers or alpha-adrenergic agents will reduce the production or humor (Black & Hawks, 2009).
Concept Care Map
See Concept Care Map.
Running head: BRADLEY GERONTOLOGY PROCESS PAPER1
Running head: BRADLEY GERONTOLOGY PROCESS PAPER1
Assessment Data
Patient Assessment
General survey.
On at 1600 on February 7, 2012, the following assessment was taken for DH. DH had a pulse of 68 beats per minute, a respiratory rate of 16 breaths per minute, a blood pressure of 143/78 mmHg, a temperature of 97.5° Fahrenheit, and an oxygen saturation rate of 95% on room air. DH reported a pain level of 2, using a numeric scale of 1-10. She stated that she had some slight discomfort in her right lower extremity, particularly her knee, but she declined any medication for it. DH stated that she did not have a history of tobacco or alcohol use. DH also stated that she felt her health, although not perfect, was under control. DH is currently recovering from right lower extremity cellulitis. She explained that she needed to use the restroom, so one of the aids wheeled her into the restroom and turned the wheelchair around to get her on to the toilet when her right lower leg and knee became pinned between the toilet and the wheelchair. She stated that it was just bruised at first, but then it became painful to bear weight on the extremity. She then noticed it began to swell and became very red and tender to the touch. She was then taken to the Emergency Room at a local hospital where they tended to admitted her for treatment.
Cardiovascular assessment.
DH had an unlabored work of breathing. Her respirations were even and deep at 16 breaths per minute. Her oxygen saturation was 95% on room air. Upon auscultation, DH’s lung sounds were clear bilaterally. She denied the presence of cough or sputum and shortness of breath.
DH’s skin turgor was good with no tenting noted. Her nail beds were pink and her capillary refill was less than three seconds. Her radial pulses were +2 bilaterally and her pedal pulses were +1 bilaterally. DH’s skin was warm and dry to the touch. No jugular vein distention was noted in DH’s assessment. Her carotid pulse was strong bilaterally. Her apical heart rate was strong and 72 beats per minute.
Abdominal assessment.
DH had active bowel sounds in all four quadrants. Her abdomen was soft and non-distended. Her last bowel movement was on February 5, 2012. She was continent of bowel and bladder. She denied any pain in her abdomen or upon defecation or urination.
Skin assessment.
DH’s skin was warm, pink, and dry to the touch. Her skin turgor was good and no tenting was noted. DH’s oral mucosa was pink and moist. She stated that she wore dentures. Her throat was pink and moist. Some skin wounds were noted during the assessment, including a right and left arm skin tear that the patient stated were from prior procedures where adhesive bandages had been applied, a right knee wound from the accident in the nursing home, a left leg hematoma, also from the accident, and bruising on her right and left elbow that the patient stated she was not sure of where they came from. The right knee wound extended to her lower lateral and anterior leg and considerable swelling was noted. The affected skin was red and warmer to the touch than the surrounding areas. The skin surrounding the area was within normal limits. The left leg hematoma and the right knee and calf wounds were cleansed with normal saline and a moistened gauze pad was applied to affected areas and secured with Kerlix. DH had a Braden Scale score of 18/23.
Neurological assessment.
DH was alert and oriented to person, place, time, and situation (Alert and Oriented x 4). Her level of consciousness was alert and her speech was clear. DH scored a 15/15 on the Glasgow Coma Scale. DH communicated appropriately and was cooperative throughout each assessment. DH denied using glasses or assistive devices for hearing. DH’s pupils were equal and reactive to light and accommodation (PERRLA). She had notable bilateral weakness in her upper and lower extremities, including her hand grasps. DH is able to stand on her own for short periods of time and can walk to the bathroom with assistance. DH scored a 10 on the Geriatric Depression Scale, indicating a mild risk for depression.
Diet and activity.
DH was up with assistance of at least one person. DH scored a three out of six on the Katz Index of Independence in Activities of Daily Living. She needs assistance bathing, transferring to the toilet, and dressing. She is able to get from the bed to the chair without assistance, eat her meals on her own, and she is continent of bowel and bladder. She is on a regular diet. She states she generally eats about 75-100% of her meals. DH enjoys being involved in group activities offered in the facility; however, she also likes to have some privacy in her room during the day to rest and relax.
Gordon’s Function Assessment
AREA OF HEALTH / SUBJECTIVE DATA / OBJECTIVE DATA / INDIRECT DATA*Identify source of indirect data / INTERPRETATION
(effective patterns or barriers/potential barriers)
HEALTH/PERCEPTION
HEALTH MANAGEMENT
General Survey, perceived health
& well-being, self-management
strategies, utilization of
preventative health behaviors
and/or services. / D.H. stated that she is tired but she is having a good day today.
Patient states pain is 2/10 on vascular scale. / Vital Signs: Respirations 16 and unlabored, pulse 68, temp 97.5°F, pulse ox 95% on room air, BP 143/78.
Patient demonstrates personal hygiene with grooming and is dressed in clothes from home.
Patient actively participates in self-care but needs assistance x 1 when becomes tired.
Patient enjoys spending time doing group activities but also enjoys private time in her room.
Patient seems to be well oriented to facility and is cooperative with staff members. / Patient being treated for right lower leg cellulitis (chart).
Patient has orders for wound treatments every 12 hours (chart).
Patient has PRN medications for pain, i.e. acetaminophen and hydrocodone (chart).
Patient is up with assistance x 1(chart). / Patient seems to get upset that she is not as independent as she was before she entered the facility.
Although patient enjoys company, she needs her privacy at times as well.
NUTRITIONAL/
METABOLIC
Patterns of food and fluid consumption,
Weight, skin turgor.
(Skin, Hair, Nails; Head & Neck;
Mouth, Nose, Sinus; swallowing, Ht., Wt) / Patient states that she will eat between 75-100 percent of her meals, depending on what is offered.
Patient states that she drinks all of the beverages offered with the meals, as well as a cup of coffee in the morning and water throughout the day. / During shift pt. ate 75% of dinner.
Skin turgor was less than three seconds, and no tenting present.
Skin was dry and warm with good color.
Oral cavity was moist and pink.
DH stated that she wore dentures.
DD is 62 inches tall, 108 lbs.
DD is partially able to perform own self care.
Patient is given polyethylene glycol once a day.
Patient is given docusate sodium once a day. / Regular diet (chart) / Patient seems to have adequate nutritional intake for dietary needs, but may need additional protein and carbohydrates for wound healing.
ELIMINATION
Patterns of excretory function &
Elimination of waste; relevant labs,
Medications, impacting, etc.
(Abdominal - bowel and bladder) / Patient states “I have no pain or urgency when I need to go to the bathroom”.
Patient states, “My last bowel movement was on 2/5/12”. / Abdomen soft symmetrical and non-distended.
Bowel sounds present in all four quadrants.
Pt. denies pain with palpitation.
Patient is given 17gm of polyethylene glycol once per day.
Patient is given 240 mg of docusate sodium once per day.
Patient may take 500mg of hydrocodone q 6h as needed for pain. / Patient may have bowel elimination problems related to opioid analgesic therapy PRN.
ACTIVITY/EXERCISE
Patterns of exercise & daily living,
self-care activities include major
body systems involved.
(Thoracic & Lung; Cardiac;
Peripheral vascular; Musculoskeletal,
vital signs) / DH denies any shortness of breath or presence of cough.
DH states that she tries to do as much as she can on her own, but needs assistance when she becomes tired during self-care activities.
DH states that she enjoys participating in activities during the day but enjoys her private time as well. / Heart sounds were regular.
Lung sounds were clear. Patient was breathing at 16 respirations per minute.
Katz ADL score was 3 out of 6.
Patient had a Braden score of 18/23.
Patient had a Fall Risk score of 6.
Patient is taking Cordarone 200 mg daily.
Patient is taking levothyroxine 75 mcg daily.
Patient is taking pregabalin 50mg once daily.
Patient is ordered 700 mg of acetaminophen or 500mg of hydrocodone for pain PRN. / Patient is up with assist (chart).
Patient is encouraged to change position in bed q 2 hours (chart).
DH had an assessment for PT ordered (chart). There were no results indicated in her chart. / Patient’s Braden score indicates a risk for developing a pressure ulcer.
Patient is cooperative and willing to try to perform self-care activities unless becomes too tired to do so.
Due to lack of mobility, patient is at a greater risk of developing infection or DVT.
SEXUALITY/ REPRODUCTION
Satisfaction with present level of
Interaction with sexual partners
(Breast; Testes; Abdominal-
Genitourinary-reproductive) / Patient stated that her husband passed away several years ago.
Patient stated that she has had no significant others since the death of her husband. / Patient’s current medications do not have an effect on sexuality or reproduction. / Found no information regarding sexuality from chart. / It was clear that speaking about her husband was a difficult subject for DH
SLEEP/REST
Patterns of sleep, rest, relaxation,
fatigue
(Appearance, behavior) / Patient stated that she sleeps about eight hours every night.
Patient stated that she normally takes a nap around 1400 for about two hours. / Patient was in physical therapy upon arrival and was did not nap that day.
Patient was pleasant and engaging in activities with others during shift. / Hydrocodone administration may lead to drowsiness (chart) / DH appears obtain a good amount of rest during the day and night.
DHseems to have a good amount of energy to complete daily activities.
COGNITIVE/ PERCEPTUAL
Patterns of thinking & ways of
Perceiving environment, orientation
Mentation, neuron status, glasses,
Hearing aids, etc. / DH was able to state her name, birthdate, where she was and her situation very descriptively.
DH stated that she was admitted to the facility in January after she was released from a local hospital. / A and O x4 person place time situation
PERRLA
Does not use hearing aid. / Nurse and physician notes indicate patient has regularly been alert and oriented (chart). / DH did not appear to have a cognitive impairment during shift.
ROLE/RELATIONSHIP
Patterns of engagement with others,
Ability to form & maintain meaningful
Relationships, assumed roles;
Family communication, response,
Visitation, occupation, community
involvement / Patient states that she used to be an accountant for a printing company in Canton.
Patient states she lived independently up until this past year.
Patient states she was residing with her daughter’s family just before she was admitted into the hospital. / Patient had several pictures of family members in her room.
Patient’s daughter visited during shift. / Nothing indicated on chart about relationships with family or within community. / Although patient preferred to live independently, she seemed to have a positive relationship with her daughter and appreciated her help.
SELF-PERCEPTION/ SELF-CONCEPT
Patterns of viewing & valuing
Self; body image & psychological
state / Patient states that when she is at home, she relies on her daughter to take her places.
DH states that she misses her independence since being admitted into the facility.
Patient states that she is not afraid to die and she has lived a good life.
Patient states that her level of anxiety is a 3 on a scale of 1-10.
Patient says that she usually has a positive view of self.
Patient feels that his level of control in his current situation is a 5 on a scale of 1 to 10.
Patient feels that his normal level of assertiveness is a 6 on a scale of 1 to 10. / DH was calm and cooperative during assessment. DH asked questions about assessment findings throughout assessment.
DH provided information about past employment history. / Patient is a DNR-CCA (chart). / DH seems to miss her independence.
DH seems to have an altered self-image due to her admission into the facility.
COPING/STRESS TOLERANCE
Stress tolerance, behaviors, patterns
of coping with stressful events &
level of effectiveness, depression,
anxiety. / Patient states that she would love to go back to living independently.
Patient states that she does not often feel very stressed. / Patient scored a 10 on the Geriatric Depression Scale, which is indicative of a slight risk of depression. / Patient is not currently ordered any medications for anxiety (chart). / Patient seems to handle stress of facility and health issues well, but it is clear that she misses her independence.
VALUE/BELIEF
Patterns of belief, values,
Perception of meaning of life that
guide choices or decision; includes
but is not limited to religious beliefs / DH states that she is Protestant and has enjoyed the services in the facility. / DH keeps a bible in her room.
DH has a cross in her room. / Patient is of Protestant faith (chart).
DH is DNR-CCA patient (chart). / DH did not indicate that she would like any religious measures taken in the event of her sudden illness or passing.
She seems to have a strong Christian faith and is actively involved in Christian activities in the facility.
Laboratory Information