Focal Points Of Nursing Care Plan
Geriatric Health History Documentation
Student Name___________________________
Focal Points of Geriatric Assessment/Grading Rubric: 1. Biographic Information (2pts) (date of visit, initials of client, race, language spoken, Advance directives, Insurance: primary, secondary)
2. Informant and reliability(3pts): (facility chart, client, family member, staff, etc.) Chief Complaint or client’s request for care
Present Illness: Present Illness or present health status
OLD CART (Onset, Location, Duration, Characteristics, Associated factors, Response to treatments tried) Progression of disease/Illness: Chronological order of events Specific s/s Duration, characteristics, location Abrupt/gradual, related …show more content…
activity Aggravating/alleviating factors: medication Treatment Pertinent negative data
3. Past Medical History(5pts) :
Allergies
Immunizations (childhood, influenza, pneumonia, shingles- provide dates if known)
Past Illness:
Illness (including childhood) with/without hospitalization, injuries, poisonings
Illnesses with hospitalization: (when and where)
Past surgical history:
Operations (hip, gallbladder, etc. and year)
Transfusions, if any
Falls: # in past year and treatment required, if any
4. Development Data (5pts)
Occupation (former and current), volunteer activities, hobbies
Adult Developmental Stage (must include theory and supporting statement)
Mental Status (Mini-Mental Health Exam, Geriatric Depression Scale)
5. Social History (5pts): Habits/current issues:
Environment (type, cleanliness, safety)
Driving (night/day, barriers to driving)
Sleep (bedtime, wake-up, quality of sleep, medication taken for sleep, naps - #, duration)
Elimination (bowel – constipation, diarrhea, how often and characteristic of stool, dietary prunes/juice; bladder – nocturia, incontinence, dribbling)
Exercise (description of any specific exercise program, aerobic, strengthening: barriers to exercise)
Nutrition (use nutritional screening tool, Gerontologic Nursing, p. 180, list score and risk status)
Use of tobacco, coffee, tea, cola, alcohol, laxatives (amounts and how often)
Sexuality (if client is comfortable addressing topic)
6. Family Health History (5pts)
Marital status, children
Place of birth, health status of siblings, parents, if living; If dead, what was cause and age at death
Family Personal/Social History
Church affiliations, social groups and support
7. ROS: Review of systems (NOT your assessment but the client’s perception of his/her health) (10pts)
General: Unusual weight changes, fatigue, skin color/ texture changes, temperature, chills, sensitivity, mentality, changes in behavior
HEENT: Headaches, diplopia, blurred vision, red eyes, painful eyes, cataracts, glaucoma, loss of visual field, oral cavity ulcers or growths, sore throat, hoarseness, glasses, contacts, dentures, or hearing aids?
Respiratory: cough, sputum, hemoptysis, dyspnea, pleuritic chest pain, wheezing, asthma, recurrent infections – pneumonia or bronchitis, occupational exposures (asbestos, pneumoconiosis), last Chest x-ray, TB, DVT or PE, sleep pattern.
Cardiac: Chest pain or pressure, palpitation, orthopnea, SOB, pedal edema, Hx of rheumatic fever, heart murmur, HTN, hyperlipidemia, Mitral valve prolapse
Gastrointestinal: weight gain/loss, change in appetite or diet pattern, nausea, vomiting, diarrhea, constipation, date of last flex. Sig/ colonoscopy, hematemesis, melena, change in stool, hemorrhoids hepatitis, PUD, Gall bladder disease, dysphagia, GERD, belching, flatus, jaundice, abdominal pain.
Genitourinary: dysuria)a, frequency, polyuria, pyuria, hematuria (dark urine/ cola colored, character of stream, decrease force of urination, nocturia, hesitancy, incontinence, nephrolithiasis, hx of UTIs, currently sexually active? Female: Menarche, menopause, postmenopausal bleeding, vaginal discharge, STDs, endometriosis, birth control methods, hormone replacement therapy, #of pregnancies, #live births, #lost pregnancies, hysterectomy, dyspareunia, last pap, breast lumps, nipple discharge, last mammogram, SBE, mastectomy. Male: hernia, testicular masses or pain, penile discharge, penile sores, prostatitis, hx prostate cancer BPH, sexual dysfunction, STDs, Prior PSAs
Musculoskeletal: Weakness, clumsiness, ataxia, lack of coordination, unusual movements, back or joint stiffness, muscle or joint pains, cramp, deformities, fractures, swelling, muscle weakness or wasting, limitation of movement, gout, Lyme disease, arthritis.
Neurologic: Seizures, temors, dizziness, tingling, sensory changes, or paresthesias, loss of feeling, loss of memory, general affect, speech problems, changes in gait or coordination
Vascular: Phlebitis, varicose veins, claudication, cramping, Raynaud’s, PAD (PVD), neck vein distention
Endocrine: Excessive thirst or appetite, cold-heat intolerance, DM, Osteoporosis
Hematologic: Anemia, pallor, lymph node swelling, bleeding, bruising, blood transfusions, toxic drugs, irradiation, chemotherapy, night sweats
Dermatologic: Rashes, moles (recent changes), birthmarks, pigmentation-color changes, jaundice, cyanosis, pallor, lumps, changes in body hair, nails
Psychological: depression, agitation, panic-anxiety, memory disturbance, personality changes, hallucinations.
8. Functional Assessment (10pts)
ADLs (feeding, bathing, dressing, toileting, grooming)
IADLs (Instrumental activities of daily living) shopping, doing laundry, housekeeping chores, using phone, opening and answering mail, ability to drive
9. Current Medication (5pts)
List all meds, prescribed and over the counter, what they are, why taken, dosages and times
10. Physical Assessment (20pts)
(Refer to Perry & Potter, Clinical Nursing Skills & Techniques, chapters 3-6)
(5) VS, (P, R, BP, Temp, ht, wt, BMI) Senses: Vision, Hearing (glasses, hearing aids)
(5) General: Well/Ill Skin: color, texture, turgor, lesions, pigmentation, ecchymosis, trauma, hair, nail condition
HEENT: Pulses, symmetry, temporal arteries
Head: Symmetry, scalp, face
Ears: Hearing, cerumen
Eyes: Strabismus/nystagmus, vision, EOMs/cover-uncover, inflammation
Nose: Nares, turbinates, hearing, aids,
Mouth/Throat: Teeth, gums, ducts, palate, tongue, pharynx, lesions
Neck: ROM, suppleness, thyroid, trachea, JVD
Lymph: Adenopathy, tenderness
(5)Chest:
Thorax; structures, breasts
Lungs: rate, effort, sounds (A&P)
Heart: rate, murmurs, pulses, bruits
Abdomen: Liver, spleen kidneys, masses, tenderness, bowels sounds GI/GU: Optional
(5) Musculoskeletal: symmetry, ROM, muscle strength, digits, feet, spinal alignment Extremities: edema, temp, clubbing, color, ulceration Neurological: Motor, sensory, coordination, balance, fall potential, reflexes Cranial Nerves (integrated)
11. SOAP (5pts) (refer to Potter & Perry, Fundamentals of Nursing, p. 391)
Subjective data (what the client states or complains of) Objective data (assessment findings; significant findings from lab, v/s, physical assessment, etc.) Assessment (pull your information together both subjective and objective; formulate nursing diagnosis) Plan (treatments, meds, etc. as well as teaching/education, recommendations, and follow up)
12. Nursing Care Plan and Nursing Diagnoses (20pts) with outcomes (goals) & interventions with rationale. (Use SMART acronym as reminder)
13. References (5pts) (Use APA format; you should be using your fundamentals book, gerontology text book, nursing diagnosis book, and possibly your drug book, lab/diagnostics reference book, med-surg book, etc.)
100 points total
Geriatric Assessment Form
History
1) Biographical Data
Date of visit______02/07/14 02/14/14_______________________________
Client’s Name (Initials only) _______________________________Age___92__ DOB _06/06/22__________Sex___M___
Race__India_____________ Language: Spoken_English, Hendi_____ Understood _______yes_____________
Advance Directives: (Living Will, DPOA, DPOA-HCD, etc.) __living will- son____________________________
Insurance: Primary: _____Medicare___________________________________________ Secondary: ____Bluecross blueshield__________________________________________
2) Source of Information (informant and reliability):
Chief Complaint/ Present Illness or present health status: (use old cart)
O became blind about 5 years ago
L eyes-blind
D permanent
C fall risk
A cannot see, uses walker, wife assist with ADL’s
R T eye drops help with eye dryness
3) Past Medical History:
Allergies: morphine, hydrocodone, cipro, sulfa, penicillin
Immunizations: influenza shot and pneumonia shot
Illnesses: glaucoma, htn
Past surgical history: cholecystectomy, appendectomy, hip replacement, hernia surgery, eye surgery
Transfusions: no transfusions
Falls: 01/2012
4) Developmental Data:
Occupation: business man, owned a liquor store in India, owned a sandwich shop in America
Volunteer activities and hobbies handyman- likes to make furniture
Adult Developmental Stage & supporting statement: Integrity- he feels like he had a successful life
Mini-Mental Health Exam/Geriatric Depression Scale results: (see last section for exam) 19/30
5) Social History/Habit/Current Issues
Environment: safe and clean
Driving: cannot drive
Sleep: sleeps most of night, wakes x2 BR
Elimination: normal BM
Exercise: daily exercise activity, walks the halls with wife
Nutrition (use nutritional screening tool, Gerontologic Nursing, p. 180, list score and risk status): 13- normal nutritional status
Use of tobacco, coffee, tea, cola, laxatives no tobacco or alcohol use. Drinks hot tea HS
Sexuality: married
6) Family Health History:
Married, divorced, widowed: married, wife
Children: 2 sons
Place of birth: Bomboi, India
Health status of living parents or siblings: both parents and all siblings have passed
Cause of death for parents or siblings: old age
Church affiliations: parsee- religion
Social groups or support: one son lives here and 2 granddaughters
7) Review of Systems (This is what you ask the client; review pp.60-62, Gerontologic Nursing)
General (what is client’s perception of his/her health)
HEENT:
Neck/Lymph: pt has full ROM in neck. Pt stated no pain in neck area
Respiratory: pt states SOB on exertion
Cardiovascular: no c/o chest pain. Pt states he has high BP
GI/GU: pt states he takes fiber daily for constipation
Musculoskeletal: pt denies any muscular pain or pain on ambulation
Neurological: pt states no memory or concentration problems
Endocrine: pt states he is not diabetic
Hematologic: pt states no blood disorders
Dermatologic: pt states no skin cancer or present acne
Psychological: pt states somewhat depressed but happy to be alive
8) Functional Assessment Activities of Daily Living
Feeding with guidance
Bathing needs assistance
Dressing needs assistance
Toileting needs assistance
Grooming needs assistance Instrumental activities of Daily Living
Preparing meals facility prepares meals, son will sometimes bring culture food items
Shopping son will shop for them
Managing money son manages money
Performing laundry tasks son takes laundry home
Housekeeping chores wife helps with cleaning, facility does weekly housekeeping
Communication such as using phone, opening mail, responding to mail, ability to drive
Uses home phone with assistance, son manages mail, can no longer drive
9) CURRENT MEDICATIONS (should list what, how much/when, and why)
Prescriptions & OTC
Medication
Dosage & Frequency
Indication (taking for ?)
Additional Information lasix 20 mg qd edema asprin
81 mg qd
CVA prevention
finasteride
5 mg qd
BPH
metoprolol
50 mg qd htn Muro 128 opth
5% one gtt qd glaucoma Right eye norvasc 5 mg HS htn fluorometholone
0.1% one gtt
Chronic eye inflammation
QID
flomax
0.4mg HS
BPH
travatan
0.004% one gtt glaucoma Both eyes
Artificial tears
QID
Dty eyes
10) Physical Assessment (your assessment, observations, etc.)
Vital Signs: BP: 119/55 HR: 53 Resp.Rate: 18 T:95.9 Ht/Wt:62 in /141lbs BMI:22
Senses: hearing, vision totally blind, hearing aides both ears
General perception (well/ill appearing) looked well but tired
Skin moist, warm, no lesions, no rashes
HEENT:
Head: head round and of proportion, no lesions, no headaches
Ears: symmetrical, hearing aides
Eyes: blind
Nose: no obstruction
Mouth/throat: upper and lower dentures
Neck & Lymph: no jvd, trachea midline
Chest:
Thorax: atropohic, symmetric
Lungs: lung sounds clear bilaterally
Heart: s1, s2 regular heart sounds
Abdomen: hypoactive bowel sounds
GI/GU (optional)
Musculoskeletal: gait steady, uses walker
Extremities: skin warm and moist, palpable bilateral pedal pulses
Neurological: alert oriented x4
Cranial nerves: pt blind and cannot follow movement
11) Evaluation: SOAP note (Potter & Perry, Fundamentals of Nursing, p. 391;SOAP note instructions at the end of this document following Reference page): S: c/o blindness, not able to care all for himself
O: observed pt wife assisting client with bathroom assistance and other ASL’s
A: depression r/t self care deficit
P: social interactions/activities
Conclusion: When asked, “Is there any additional information that we have not talked about that would be important for me to know?” the client/family responded: “No, I’m ready to nap.”
Care plan: As listed in your syllabus:
12) Nursing Care Plan
The Nursing Care Plan links theory to clinical practice via a written table.
Care Plans facilitate organization of data and application of theory to developing plans of care for individual clients.
The following format is to be used to develop a client care plan:
ITT Technical Institute
Associate of Science in Nursing
Nursing Care
Plan
Client initials: _RF______Client age: _92_____ Support system: __wife, son_____________________________
Admitting diagnosis: hip fracture__________________________________________________________
Secondary diagnoses: blindness__________________________________________________________
Preclinical Data Assessment and Development of Plan of Care Revision Notes
Admission (summarize events leading up to point of admission):
He fell in 2010 caused him to have a fractured hip.
He was admitted because of blindness and hip fracture
Summary of current visit history (summarize client course since admission):
He does not really like to be here but he tries to be happy for his wife.
They walk around and talk to people and engage in activities together.
His wife helps a lot with taking care of him.
Client social/cultural/spiritual/developmental/support system/environmental factors:
Does engage in facility activities. Does not usually leave the facility due to blindness.
Religion is parsee, they have a temple in India but here in America they do not celebrate their religion.
Current treatments and medications (list any treatments; list meds if any other than previous list):
He gets several eye frops for his dry eyes and glaucoma.
Pertinent lab/X-ray/diagnostic procedure results (abnormal values only):
1/27/2010 left hip hemiarthroplasty
Significant assessment findings:
Overall in great health
He does seem to feel helpless and powerless
Because he is blind and needs so much help with ADL’s
Nursing Care Plan
Priority nursing diagnoses (3 diagnoses) and one goal/outcome for each (timed & measurable)
Nursing diagnosis a).self care deficit r/t blindness Goal: pt will identify what is useful in optimizing the autonomy and independence of the pt by the end of shift today.
Nursing diagnosis b). fall risk r/t blindness Goal: pt will remain free of any falls today.
Nursing diagnosis c). ineffective coping r/t loss of vision Goal: pt will remain free of destructive behavior toward self or others on today’s shift.
Use your Nursing Diagnosis book:
Priority nursing interventions (interventions/implementation): 7 interventions (with rationale) for each diagnosis, timed and measurable, where applicable.
Interventions:
1a maintain individuality with hairstyle, jewelry, clothing, everyday with dressing Rationale: helps define a persons identity and promote self esteem
2a encourage client to help as much as possible with ADL’s everyday Rationale: performing self care helps maintain independence
3a provide explanation of everything you do every shift Rationale: this will reduce anxiety
4a include regular exercise and walking program in plan of care BID Rationale: exercise improves functional abilities
5a provide privacy and preserve dignity every care interval Rationale: maintains their autonomy
6a teach family members to see dressing as an opportunity to promote independence and better quality of life Rationale: this is a time to retain independence
7a involve the client in planning of care Rationale: it is important for the client to be involved with their health plan
Interventions:
1b staff will instruct client to wear proper foot wear and the beginning of the day Rationale: this will prevent client from slipping and falling
2b keep walker and wheelchair in easy reach at all times throughout the day Rationale: pt will have less chance of falling if walker is in easy reach
3b encourage resident to use nursing call cord throughout the day Rationale: so pt will have easy access to help when needed 4b thoroughly orient pt to environment daily Rationale: this will help guide pt
5b avoid use of restraints every shift Rationale: there is no increase in falls without a restraint
6b use a high risk sign on door everyday Rationale: this will alert others
7b keep room free of clutter TID. Keep a clean pathway Rationale: this will prevent anything in the way of causing a fall
Interventions:
1c when caring for resident everyone should use verbal and nonverbal therapeutic communication approaches including empathy, active listening, encourage client to express emotions. Rationale: communication skills contribute to the well being of clients and minimizes psychosocial factors
2c encourage client to describe previous stressors and mechanisms used during daily assessment Rationale: identifying symptoms can decrease depression
3c be supportive of coping behaviors, allow client to relax Rationale: a supportive relationship has a positive effect on coping
4c encourage use of social support resources every week Rationale: high levels of social support improves coping
5c actively listen to complaints and concerns every shift Rationale: quality of care can be improved by active listening
6c engage the client in reminiscence anytime you communicate with the client Rationale: life reviews as an intervention had a significant effect of lowering depression
7c teach relaxation techniques to be used once a day Rationale: mindful mediation was found to promote health promotion
Mini-Mental Status Examination
The Mini-Mental Status Examination offers a quick and simple way to quantify cognitive function and screen for cognitive loss. It tests the individual’s orientation, attention, calculation, recall, language and motor skills.
Each section of the test involves a related series of questions or commands. The individual receives one point for each correct answer.
To give the examination, seat the individual in a quiet, well-lit room. Ask him/her to listen carefully and to answer each question as accurately as he/she can.
Don’t time the test but score it right away. To score, add the number of correct responses. The individual can receive a maximum score of 30 points.
A score below 20 usually indicates cognitive impairment.
The Mini-Mental Status Examination
Initials of pt: ____________________________________ DOB: __________________
Years of School: ____________________________ Date of Exam: ___________
Orientation to Time Correct ______ Incorrect ______
What is today’s date? ___________________
What is the month? ___________________
What is the year? ____________________
What is the day of the week today? _________________
What season is it?
Total: ____ /5
Orientation to Place
Whose home is this?
What room is this?
What city are we in?
What county are we in?
What state are we in?
Total: ____ /5
Immediate Recall
Ask if you may test his/her memory. Then say “ball”, “flag”, “tree” clearly and slowly, about 1 second for each. After you have said all 3 words, ask him/her to repeat them – the first repetition determines the score (0-3):
Ball
Flag
Tree
Total: ____ /3
Ask the individual to spell the word ”WORLD” backwards. The score is the number of letters in correct position.
D
L
R
O
W Total:_____ /5
Delayed Verbal Recall
Ask the individual to recall the 3 words you previously asked him/her to remember.
Ball
Flag
Tree
Total: _____ /3
Naming
Show the individual a wristwatch and ask him/her what it is. Repeat for pencil.
Watch
Pencil Total:______/2
Repetition
Ask the individual to repeat the following:
“No if, ands, or buts”
Total ____/1
3-Stage Command
Give the individual a plain piece of paper and say, “Take the paper in your hand, fold it in half, and put it on the floor.”
Takes
Folds
Puts
Total ____/3
Reading
Hold up the card reading: “Close your eyes” so the individual can see it clearly.
Ask him/her to read it and do what it says. Score correctly only if the individual actually closes his/her eyes.
Total __/1
Writing
Give the individual a piece of paper and ask him/her to write a sentence. It is to be written spontaneously. It must contain a subject and verb and be sensible.
Total____/1
Copying
Give the individual a piece of paper and ask him/her to copy a design of two intersecting shapes.
One point is awarded for correctly copying the shapes. All angles on both figures must be present, and the figures must have one overlapping angle. Total ___/1
Total Score:_____ /30
*Your evaluation of this exam: (using your book, state if the client has cognitive impairment or not based on this tool)
Geriatric Depression Scale: Short Form
Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO
3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO
7. Do you feel happy most of the time? YES / NO
8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO
10. Do you feel you have more problems with memory than most? YES / NO
11. Do you think it is wonderful to be alive now? YES / NO
12. Do you feel pretty worthless the way you are now? YES / NO
13. Do you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO
Answers in bold indicate depression. Score 1 point for each bolded answer.
A score > 5 points is suggestive of depression.
A score ≥ 10 points is almost always indicative of depression. A score > 5 points should warrant a follow-up comprehensive assessment.
Source: http://www.stanford.edu/~yesavage/GDS.html
*YOUR EVALUATION OF THIS EXAM: (using your book, state if the client has depression or not based on this tool)
13. List books in APA format used in this care plan: Fundamentals, Gerontology text, nursing diagnosis book, drug book, etc.)
References
SOAP note instructions
1
Write the "S" or subjective section. This includes everything the client reports. Information in this section usually relates to the client 's complaint in his own words and includes any reported symptoms, their severity and their duration. Record the subjective information --- the "S" in SOAP --- to document symptoms and complaints as reported by the client in her own words. Include symptom examples, such as pain, vomiting and diarrhea. Document the frequency, onset, location and duration of symptoms.
2
Write the "O" or objective section. This section details any information you observe while listening to the client 's complaints and performing an examination. If you notice ankle swelling as the client reports pain, this is the section where you record it. Take measurements and vitals, such as oxygen saturation, blood pressure and pulse to document objective information. This is the "O" in SOAP. Include measurable signs, such as lab test results, vitals, weight and height, in the objective data section. Perform a head-to-toe clinical exam of the client 's body 's systems to rule out various diagnoses. Document exam findings in the "O" section.
3
Write the "A" or assessment section. Here, you include your diagnostic nursing assessment, as well as any lab test results you perform. If you are monitoring rather than assessing a client, you note any changes in the client 's condition here. Offer a nursing diagnosis in the "A" or assessment section, which includes both subjective and objective information. Confirm and synthesize subjective and objective notes to create assessment data. Record a nursing diagnosis, such as "at risk for a sexually transmitted infection," in this section. Record, for example, "client complains of shortness of breath" in the subjective section. Document "client is wheezing in left and right upper lobes upon auscultation" in the objective section after performing a clinical exam. Record "client is short of breath" in the assessment section as confirmation of data reported in the subjective and objective sections.
4
Write the "P" or plan section. This is the plan for treatment, including what medications or other therapies you will administer or advise. This section should be actionable and thoroughly map out the course of treatment, as well as the intended outcomes and any necessary follow-ups, referrals or additional testing that is needed. Document the "P," which is the "plan" of treatment, last. Record long and short-term treatment actions, such as "antibiotic therapy," "follow-up X-ray in three weeks," "client education about Foley catheter insertion" or "physical therapy consult." Include relief measures or actions that worsen the client 's symptoms. Provide an evaluation of the success or failure of treatment interventions.
Read more: http://www.ehow.com/how_5020028_write-nurses-soap.html#ixzz2ecfwZ0ST
Student Name___________________________
Focal Points of Geriatric Assessment/Grading Rubric: 1. Biographic Information (2pts) (date of visit, initials of client, race, language spoken, Advance directives, Insurance: primary, secondary)
2. Informant and reliability(3pts): (facility chart, client, family member, staff, etc.) Chief Complaint or client’s request for care
Present Illness: Present Illness or present health status
OLD CART (Onset, Location, Duration, Characteristics, Associated factors, Response to treatments tried) Progression of disease/Illness: Chronological order of events Specific s/s Duration, characteristics, location Abrupt/gradual, related …show more content…
activity Aggravating/alleviating factors: medication Treatment Pertinent negative data
3. Past Medical History(5pts) :
Allergies
Immunizations (childhood, influenza, pneumonia, shingles- provide dates if known)
Past Illness:
Illness (including childhood) with/without hospitalization, injuries, poisonings
Illnesses with hospitalization: (when and where)
Past surgical history:
Operations (hip, gallbladder, etc. and year)
Transfusions, if any
Falls: # in past year and treatment required, if any
4. Development Data (5pts)
Occupation (former and current), volunteer activities, hobbies
Adult Developmental Stage (must include theory and supporting statement)
Mental Status (Mini-Mental Health Exam, Geriatric Depression Scale)
5. Social History (5pts): Habits/current issues:
Environment (type, cleanliness, safety)
Driving (night/day, barriers to driving)
Sleep (bedtime, wake-up, quality of sleep, medication taken for sleep, naps - #, duration)
Elimination (bowel – constipation, diarrhea, how often and characteristic of stool, dietary prunes/juice; bladder – nocturia, incontinence, dribbling)
Exercise (description of any specific exercise program, aerobic, strengthening: barriers to exercise)
Nutrition (use nutritional screening tool, Gerontologic Nursing, p. 180, list score and risk status)
Use of tobacco, coffee, tea, cola, alcohol, laxatives (amounts and how often)
Sexuality (if client is comfortable addressing topic)
6. Family Health History (5pts)
Marital status, children
Place of birth, health status of siblings, parents, if living; If dead, what was cause and age at death
Family Personal/Social History
Church affiliations, social groups and support
7. ROS: Review of systems (NOT your assessment but the client’s perception of his/her health) (10pts)
General: Unusual weight changes, fatigue, skin color/ texture changes, temperature, chills, sensitivity, mentality, changes in behavior
HEENT: Headaches, diplopia, blurred vision, red eyes, painful eyes, cataracts, glaucoma, loss of visual field, oral cavity ulcers or growths, sore throat, hoarseness, glasses, contacts, dentures, or hearing aids?
Respiratory: cough, sputum, hemoptysis, dyspnea, pleuritic chest pain, wheezing, asthma, recurrent infections – pneumonia or bronchitis, occupational exposures (asbestos, pneumoconiosis), last Chest x-ray, TB, DVT or PE, sleep pattern.
Cardiac: Chest pain or pressure, palpitation, orthopnea, SOB, pedal edema, Hx of rheumatic fever, heart murmur, HTN, hyperlipidemia, Mitral valve prolapse
Gastrointestinal: weight gain/loss, change in appetite or diet pattern, nausea, vomiting, diarrhea, constipation, date of last flex. Sig/ colonoscopy, hematemesis, melena, change in stool, hemorrhoids hepatitis, PUD, Gall bladder disease, dysphagia, GERD, belching, flatus, jaundice, abdominal pain.
Genitourinary: dysuria)a, frequency, polyuria, pyuria, hematuria (dark urine/ cola colored, character of stream, decrease force of urination, nocturia, hesitancy, incontinence, nephrolithiasis, hx of UTIs, currently sexually active? Female: Menarche, menopause, postmenopausal bleeding, vaginal discharge, STDs, endometriosis, birth control methods, hormone replacement therapy, #of pregnancies, #live births, #lost pregnancies, hysterectomy, dyspareunia, last pap, breast lumps, nipple discharge, last mammogram, SBE, mastectomy. Male: hernia, testicular masses or pain, penile discharge, penile sores, prostatitis, hx prostate cancer BPH, sexual dysfunction, STDs, Prior PSAs
Musculoskeletal: Weakness, clumsiness, ataxia, lack of coordination, unusual movements, back or joint stiffness, muscle or joint pains, cramp, deformities, fractures, swelling, muscle weakness or wasting, limitation of movement, gout, Lyme disease, arthritis.
Neurologic: Seizures, temors, dizziness, tingling, sensory changes, or paresthesias, loss of feeling, loss of memory, general affect, speech problems, changes in gait or coordination
Vascular: Phlebitis, varicose veins, claudication, cramping, Raynaud’s, PAD (PVD), neck vein distention
Endocrine: Excessive thirst or appetite, cold-heat intolerance, DM, Osteoporosis
Hematologic: Anemia, pallor, lymph node swelling, bleeding, bruising, blood transfusions, toxic drugs, irradiation, chemotherapy, night sweats
Dermatologic: Rashes, moles (recent changes), birthmarks, pigmentation-color changes, jaundice, cyanosis, pallor, lumps, changes in body hair, nails
Psychological: depression, agitation, panic-anxiety, memory disturbance, personality changes, hallucinations.
8. Functional Assessment (10pts)
ADLs (feeding, bathing, dressing, toileting, grooming)
IADLs (Instrumental activities of daily living) shopping, doing laundry, housekeeping chores, using phone, opening and answering mail, ability to drive
9. Current Medication (5pts)
List all meds, prescribed and over the counter, what they are, why taken, dosages and times
10. Physical Assessment (20pts)
(Refer to Perry & Potter, Clinical Nursing Skills & Techniques, chapters 3-6)
(5) VS, (P, R, BP, Temp, ht, wt, BMI) Senses: Vision, Hearing (glasses, hearing aids)
(5) General: Well/Ill Skin: color, texture, turgor, lesions, pigmentation, ecchymosis, trauma, hair, nail condition
HEENT: Pulses, symmetry, temporal arteries
Head: Symmetry, scalp, face
Ears: Hearing, cerumen
Eyes: Strabismus/nystagmus, vision, EOMs/cover-uncover, inflammation
Nose: Nares, turbinates, hearing, aids,
Mouth/Throat: Teeth, gums, ducts, palate, tongue, pharynx, lesions
Neck: ROM, suppleness, thyroid, trachea, JVD
Lymph: Adenopathy, tenderness
(5)Chest:
Thorax; structures, breasts
Lungs: rate, effort, sounds (A&P)
Heart: rate, murmurs, pulses, bruits
Abdomen: Liver, spleen kidneys, masses, tenderness, bowels sounds GI/GU: Optional
(5) Musculoskeletal: symmetry, ROM, muscle strength, digits, feet, spinal alignment Extremities: edema, temp, clubbing, color, ulceration Neurological: Motor, sensory, coordination, balance, fall potential, reflexes Cranial Nerves (integrated)
11. SOAP (5pts) (refer to Potter & Perry, Fundamentals of Nursing, p. 391)
Subjective data (what the client states or complains of) Objective data (assessment findings; significant findings from lab, v/s, physical assessment, etc.) Assessment (pull your information together both subjective and objective; formulate nursing diagnosis) Plan (treatments, meds, etc. as well as teaching/education, recommendations, and follow up)
12. Nursing Care Plan and Nursing Diagnoses (20pts) with outcomes (goals) & interventions with rationale. (Use SMART acronym as reminder)
13. References (5pts) (Use APA format; you should be using your fundamentals book, gerontology text book, nursing diagnosis book, and possibly your drug book, lab/diagnostics reference book, med-surg book, etc.)
100 points total
Geriatric Assessment Form
History
1) Biographical Data
Date of visit______02/07/14 02/14/14_______________________________
Client’s Name (Initials only) _______________________________Age___92__ DOB _06/06/22__________Sex___M___
Race__India_____________ Language: Spoken_English, Hendi_____ Understood _______yes_____________
Advance Directives: (Living Will, DPOA, DPOA-HCD, etc.) __living will- son____________________________
Insurance: Primary: _____Medicare___________________________________________ Secondary: ____Bluecross blueshield__________________________________________
2) Source of Information (informant and reliability):
Chief Complaint/ Present Illness or present health status: (use old cart)
O became blind about 5 years ago
L eyes-blind
D permanent
C fall risk
A cannot see, uses walker, wife assist with ADL’s
R T eye drops help with eye dryness
3) Past Medical History:
Allergies: morphine, hydrocodone, cipro, sulfa, penicillin
Immunizations: influenza shot and pneumonia shot
Illnesses: glaucoma, htn
Past surgical history: cholecystectomy, appendectomy, hip replacement, hernia surgery, eye surgery
Transfusions: no transfusions
Falls: 01/2012
4) Developmental Data:
Occupation: business man, owned a liquor store in India, owned a sandwich shop in America
Volunteer activities and hobbies handyman- likes to make furniture
Adult Developmental Stage & supporting statement: Integrity- he feels like he had a successful life
Mini-Mental Health Exam/Geriatric Depression Scale results: (see last section for exam) 19/30
5) Social History/Habit/Current Issues
Environment: safe and clean
Driving: cannot drive
Sleep: sleeps most of night, wakes x2 BR
Elimination: normal BM
Exercise: daily exercise activity, walks the halls with wife
Nutrition (use nutritional screening tool, Gerontologic Nursing, p. 180, list score and risk status): 13- normal nutritional status
Use of tobacco, coffee, tea, cola, laxatives no tobacco or alcohol use. Drinks hot tea HS
Sexuality: married
6) Family Health History:
Married, divorced, widowed: married, wife
Children: 2 sons
Place of birth: Bomboi, India
Health status of living parents or siblings: both parents and all siblings have passed
Cause of death for parents or siblings: old age
Church affiliations: parsee- religion
Social groups or support: one son lives here and 2 granddaughters
7) Review of Systems (This is what you ask the client; review pp.60-62, Gerontologic Nursing)
General (what is client’s perception of his/her health)
HEENT:
Neck/Lymph: pt has full ROM in neck. Pt stated no pain in neck area
Respiratory: pt states SOB on exertion
Cardiovascular: no c/o chest pain. Pt states he has high BP
GI/GU: pt states he takes fiber daily for constipation
Musculoskeletal: pt denies any muscular pain or pain on ambulation
Neurological: pt states no memory or concentration problems
Endocrine: pt states he is not diabetic
Hematologic: pt states no blood disorders
Dermatologic: pt states no skin cancer or present acne
Psychological: pt states somewhat depressed but happy to be alive
8) Functional Assessment Activities of Daily Living
Feeding with guidance
Bathing needs assistance
Dressing needs assistance
Toileting needs assistance
Grooming needs assistance Instrumental activities of Daily Living
Preparing meals facility prepares meals, son will sometimes bring culture food items
Shopping son will shop for them
Managing money son manages money
Performing laundry tasks son takes laundry home
Housekeeping chores wife helps with cleaning, facility does weekly housekeeping
Communication such as using phone, opening mail, responding to mail, ability to drive
Uses home phone with assistance, son manages mail, can no longer drive
9) CURRENT MEDICATIONS (should list what, how much/when, and why)
Prescriptions & OTC
Medication
Dosage & Frequency
Indication (taking for ?)
Additional Information lasix 20 mg qd edema asprin
81 mg qd
CVA prevention
finasteride
5 mg qd
BPH
metoprolol
50 mg qd htn Muro 128 opth
5% one gtt qd glaucoma Right eye norvasc 5 mg HS htn fluorometholone
0.1% one gtt
Chronic eye inflammation
QID
flomax
0.4mg HS
BPH
travatan
0.004% one gtt glaucoma Both eyes
Artificial tears
QID
Dty eyes
10) Physical Assessment (your assessment, observations, etc.)
Vital Signs: BP: 119/55 HR: 53 Resp.Rate: 18 T:95.9 Ht/Wt:62 in /141lbs BMI:22
Senses: hearing, vision totally blind, hearing aides both ears
General perception (well/ill appearing) looked well but tired
Skin moist, warm, no lesions, no rashes
HEENT:
Head: head round and of proportion, no lesions, no headaches
Ears: symmetrical, hearing aides
Eyes: blind
Nose: no obstruction
Mouth/throat: upper and lower dentures
Neck & Lymph: no jvd, trachea midline
Chest:
Thorax: atropohic, symmetric
Lungs: lung sounds clear bilaterally
Heart: s1, s2 regular heart sounds
Abdomen: hypoactive bowel sounds
GI/GU (optional)
Musculoskeletal: gait steady, uses walker
Extremities: skin warm and moist, palpable bilateral pedal pulses
Neurological: alert oriented x4
Cranial nerves: pt blind and cannot follow movement
11) Evaluation: SOAP note (Potter & Perry, Fundamentals of Nursing, p. 391;SOAP note instructions at the end of this document following Reference page): S: c/o blindness, not able to care all for himself
O: observed pt wife assisting client with bathroom assistance and other ASL’s
A: depression r/t self care deficit
P: social interactions/activities
Conclusion: When asked, “Is there any additional information that we have not talked about that would be important for me to know?” the client/family responded: “No, I’m ready to nap.”
Care plan: As listed in your syllabus:
12) Nursing Care Plan
The Nursing Care Plan links theory to clinical practice via a written table.
Care Plans facilitate organization of data and application of theory to developing plans of care for individual clients.
The following format is to be used to develop a client care plan:
ITT Technical Institute
Associate of Science in Nursing
Nursing Care
Plan
Client initials: _RF______Client age: _92_____ Support system: __wife, son_____________________________
Admitting diagnosis: hip fracture__________________________________________________________
Secondary diagnoses: blindness__________________________________________________________
Preclinical Data Assessment and Development of Plan of Care Revision Notes
Admission (summarize events leading up to point of admission):
He fell in 2010 caused him to have a fractured hip.
He was admitted because of blindness and hip fracture
Summary of current visit history (summarize client course since admission):
He does not really like to be here but he tries to be happy for his wife.
They walk around and talk to people and engage in activities together.
His wife helps a lot with taking care of him.
Client social/cultural/spiritual/developmental/support system/environmental factors:
Does engage in facility activities. Does not usually leave the facility due to blindness.
Religion is parsee, they have a temple in India but here in America they do not celebrate their religion.
Current treatments and medications (list any treatments; list meds if any other than previous list):
He gets several eye frops for his dry eyes and glaucoma.
Pertinent lab/X-ray/diagnostic procedure results (abnormal values only):
1/27/2010 left hip hemiarthroplasty
Significant assessment findings:
Overall in great health
He does seem to feel helpless and powerless
Because he is blind and needs so much help with ADL’s
Nursing Care Plan
Priority nursing diagnoses (3 diagnoses) and one goal/outcome for each (timed & measurable)
Nursing diagnosis a).self care deficit r/t blindness Goal: pt will identify what is useful in optimizing the autonomy and independence of the pt by the end of shift today.
Nursing diagnosis b). fall risk r/t blindness Goal: pt will remain free of any falls today.
Nursing diagnosis c). ineffective coping r/t loss of vision Goal: pt will remain free of destructive behavior toward self or others on today’s shift.
Use your Nursing Diagnosis book:
Priority nursing interventions (interventions/implementation): 7 interventions (with rationale) for each diagnosis, timed and measurable, where applicable.
Interventions:
1a maintain individuality with hairstyle, jewelry, clothing, everyday with dressing Rationale: helps define a persons identity and promote self esteem
2a encourage client to help as much as possible with ADL’s everyday Rationale: performing self care helps maintain independence
3a provide explanation of everything you do every shift Rationale: this will reduce anxiety
4a include regular exercise and walking program in plan of care BID Rationale: exercise improves functional abilities
5a provide privacy and preserve dignity every care interval Rationale: maintains their autonomy
6a teach family members to see dressing as an opportunity to promote independence and better quality of life Rationale: this is a time to retain independence
7a involve the client in planning of care Rationale: it is important for the client to be involved with their health plan
Interventions:
1b staff will instruct client to wear proper foot wear and the beginning of the day Rationale: this will prevent client from slipping and falling
2b keep walker and wheelchair in easy reach at all times throughout the day Rationale: pt will have less chance of falling if walker is in easy reach
3b encourage resident to use nursing call cord throughout the day Rationale: so pt will have easy access to help when needed 4b thoroughly orient pt to environment daily Rationale: this will help guide pt
5b avoid use of restraints every shift Rationale: there is no increase in falls without a restraint
6b use a high risk sign on door everyday Rationale: this will alert others
7b keep room free of clutter TID. Keep a clean pathway Rationale: this will prevent anything in the way of causing a fall
Interventions:
1c when caring for resident everyone should use verbal and nonverbal therapeutic communication approaches including empathy, active listening, encourage client to express emotions. Rationale: communication skills contribute to the well being of clients and minimizes psychosocial factors
2c encourage client to describe previous stressors and mechanisms used during daily assessment Rationale: identifying symptoms can decrease depression
3c be supportive of coping behaviors, allow client to relax Rationale: a supportive relationship has a positive effect on coping
4c encourage use of social support resources every week Rationale: high levels of social support improves coping
5c actively listen to complaints and concerns every shift Rationale: quality of care can be improved by active listening
6c engage the client in reminiscence anytime you communicate with the client Rationale: life reviews as an intervention had a significant effect of lowering depression
7c teach relaxation techniques to be used once a day Rationale: mindful mediation was found to promote health promotion
Mini-Mental Status Examination
The Mini-Mental Status Examination offers a quick and simple way to quantify cognitive function and screen for cognitive loss. It tests the individual’s orientation, attention, calculation, recall, language and motor skills.
Each section of the test involves a related series of questions or commands. The individual receives one point for each correct answer.
To give the examination, seat the individual in a quiet, well-lit room. Ask him/her to listen carefully and to answer each question as accurately as he/she can.
Don’t time the test but score it right away. To score, add the number of correct responses. The individual can receive a maximum score of 30 points.
A score below 20 usually indicates cognitive impairment.
The Mini-Mental Status Examination
Initials of pt: ____________________________________ DOB: __________________
Years of School: ____________________________ Date of Exam: ___________
Orientation to Time Correct ______ Incorrect ______
What is today’s date? ___________________
What is the month? ___________________
What is the year? ____________________
What is the day of the week today? _________________
What season is it?
Total: ____ /5
Orientation to Place
Whose home is this?
What room is this?
What city are we in?
What county are we in?
What state are we in?
Total: ____ /5
Immediate Recall
Ask if you may test his/her memory. Then say “ball”, “flag”, “tree” clearly and slowly, about 1 second for each. After you have said all 3 words, ask him/her to repeat them – the first repetition determines the score (0-3):
Ball
Flag
Tree
Total: ____ /3
Ask the individual to spell the word ”WORLD” backwards. The score is the number of letters in correct position.
D
L
R
O
W Total:_____ /5
Delayed Verbal Recall
Ask the individual to recall the 3 words you previously asked him/her to remember.
Ball
Flag
Tree
Total: _____ /3
Naming
Show the individual a wristwatch and ask him/her what it is. Repeat for pencil.
Watch
Pencil Total:______/2
Repetition
Ask the individual to repeat the following:
“No if, ands, or buts”
Total ____/1
3-Stage Command
Give the individual a plain piece of paper and say, “Take the paper in your hand, fold it in half, and put it on the floor.”
Takes
Folds
Puts
Total ____/3
Reading
Hold up the card reading: “Close your eyes” so the individual can see it clearly.
Ask him/her to read it and do what it says. Score correctly only if the individual actually closes his/her eyes.
Total __/1
Writing
Give the individual a piece of paper and ask him/her to write a sentence. It is to be written spontaneously. It must contain a subject and verb and be sensible.
Total____/1
Copying
Give the individual a piece of paper and ask him/her to copy a design of two intersecting shapes.
One point is awarded for correctly copying the shapes. All angles on both figures must be present, and the figures must have one overlapping angle. Total ___/1
Total Score:_____ /30
*Your evaluation of this exam: (using your book, state if the client has cognitive impairment or not based on this tool)
Geriatric Depression Scale: Short Form
Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO
3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO
7. Do you feel happy most of the time? YES / NO
8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO
10. Do you feel you have more problems with memory than most? YES / NO
11. Do you think it is wonderful to be alive now? YES / NO
12. Do you feel pretty worthless the way you are now? YES / NO
13. Do you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO
Answers in bold indicate depression. Score 1 point for each bolded answer.
A score > 5 points is suggestive of depression.
A score ≥ 10 points is almost always indicative of depression. A score > 5 points should warrant a follow-up comprehensive assessment.
Source: http://www.stanford.edu/~yesavage/GDS.html
*YOUR EVALUATION OF THIS EXAM: (using your book, state if the client has depression or not based on this tool)
13. List books in APA format used in this care plan: Fundamentals, Gerontology text, nursing diagnosis book, drug book, etc.)
References
SOAP note instructions
1
Write the "S" or subjective section. This includes everything the client reports. Information in this section usually relates to the client 's complaint in his own words and includes any reported symptoms, their severity and their duration. Record the subjective information --- the "S" in SOAP --- to document symptoms and complaints as reported by the client in her own words. Include symptom examples, such as pain, vomiting and diarrhea. Document the frequency, onset, location and duration of symptoms.
2
Write the "O" or objective section. This section details any information you observe while listening to the client 's complaints and performing an examination. If you notice ankle swelling as the client reports pain, this is the section where you record it. Take measurements and vitals, such as oxygen saturation, blood pressure and pulse to document objective information. This is the "O" in SOAP. Include measurable signs, such as lab test results, vitals, weight and height, in the objective data section. Perform a head-to-toe clinical exam of the client 's body 's systems to rule out various diagnoses. Document exam findings in the "O" section.
3
Write the "A" or assessment section. Here, you include your diagnostic nursing assessment, as well as any lab test results you perform. If you are monitoring rather than assessing a client, you note any changes in the client 's condition here. Offer a nursing diagnosis in the "A" or assessment section, which includes both subjective and objective information. Confirm and synthesize subjective and objective notes to create assessment data. Record a nursing diagnosis, such as "at risk for a sexually transmitted infection," in this section. Record, for example, "client complains of shortness of breath" in the subjective section. Document "client is wheezing in left and right upper lobes upon auscultation" in the objective section after performing a clinical exam. Record "client is short of breath" in the assessment section as confirmation of data reported in the subjective and objective sections.
4
Write the "P" or plan section. This is the plan for treatment, including what medications or other therapies you will administer or advise. This section should be actionable and thoroughly map out the course of treatment, as well as the intended outcomes and any necessary follow-ups, referrals or additional testing that is needed. Document the "P," which is the "plan" of treatment, last. Record long and short-term treatment actions, such as "antibiotic therapy," "follow-up X-ray in three weeks," "client education about Foley catheter insertion" or "physical therapy consult." Include relief measures or actions that worsen the client 's symptoms. Provide an evaluation of the success or failure of treatment interventions.
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