Preview

Geriatric History and Physical

Powerful Essays
Open Document
Open Document
2915 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Geriatric History and Physical
Geriatric History and Physical with Problem List and Plan
California State University, Dominguez Hills
School of Nursing

Health Assessment Lab

BSN 381L


General Patient Information
Client: 81-year-old Caucasian/Italian female
Source: Client, seems reliable
Marital status: Widower
Religion: Catholic

Occupation: House wife
Formal education: High school
Primary language: English, written and spoken
Secondary: None
Reason for Seeking Care: Shortness of breath and productive cough.
History of Present Illness: Recurrent episodes of shortness of breathe and productive cough since 2008. First episode occurred when she was in her early 80’s. She was awakened in the middle of the night with a very painful right-sided chest pain and cough. There was no warning of a problem. She reports the pain was “tight and pounding”. The pain was a 10 on a numeric scale 0-10 lasting about 25 minutes. Patient states her cough worsens when walking long distances, especially without using her walker and her breathing becomes labored. She states her cough usually lasts about three days but has noticed it becoming more persistent and feels the need to cough up phlegm. She saw a physician for that episode. Diagnostic test confirmed a diagnosis of Chronic Obstructive Pulmonary Disease when she had her first episode of these symptoms. Her lung sounds presented with some wheezing on the upper lungs bilaterally, she had rapid shallow breathing with a respiration of 24. Upon walking long distances she becomes emotionally anxious; rest does not relieve the client’s pain immediately. She was treated with a breathing treatment and aspirin. She tries to limit walking long distances, if necessary she will depend on using her walker. She states her pain from walking is accompanied by dizziness, which limits her mobility and is controlled by taking her medication Meclizine. She had another episode two years ago when getting off an airplane returning from

You May Also Find These Documents Helpful

  • Satisfactory Essays

    Epidemology Case Study 3

    • 281 Words
    • 2 Pages

    R.S. has smoked for many years and has developed chronic bronchitis, a chronic obstructive pulmonary disease (COPD). He also has a history of coronary artery disease and peripheral arterial vascular disease. His arterial blood gas (ABG) values are pH = 7.32, PaCO2 = 60 mm Hg, PaO2 = 50 mm Hg, HCO3- = 30 mEq/L. His hematocrit is 52% with normal red cell indices. He is using an inhaled ß2 agonist and theophylline to manage his respiratory disease. At this clinic visit, it is noted on a chest x-ray that R.S. has an area of consolidation in his right lower lobe that is thought to be consistent with pneumonia.…

    • 281 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    Chronic bronchitis B. Bronchial Asthma * Recurrent and reversible shortness of breath * Occurs when the airways of the lungs become narrow as a result of: * Bronchospasms * Inflammation of the bronchial mucosa * Edema of the bronchial mucosa * Production of viscid mucus * Alveolar ducts/alveoli remain open, but airflow to them is obstructed * Symptoms * Wheezing * Difficulty breathing C. Asthma *…

    • 5705 Words
    • 23 Pages
    Good Essays
  • Good Essays

    Chronic obstructive pulmonary disease (COPD) is composed of two related diseases, chronic bronchitis and emphysema. He is likely to have a chronic or recurrent productive cough that is over three months to two successive years. He will experience shortness of breath on exertion, sputum production and frequently develop hypoxemia, which could lead to cyanosis.…

    • 465 Words
    • 2 Pages
    Good Essays
  • Satisfactory Essays

    6. Loss of subcutaneous tissue can reduce the ability of older adults to regulate body temperature, leading to an increased risk for __hypothermia____.…

    • 1344 Words
    • 6 Pages
    Satisfactory Essays
  • Powerful Essays

    COPD Case Study: Emphysema

    • 1719 Words
    • 7 Pages

    D.Z., a 65-year-old man, is admitted to a medical floor for exacerbation of his chronic obstructive pulmonary disease (COPD; emphysema). He has a past medical history of hypertension, which has been well controlled by Enalapril (Vasotec) for the past 6 years. He has had pneumonia yearly for the past 3 years, and has been a 2-pack-a-day smoker for 38 years. He appears as a cachectic man who is experiencing difficulty breathing at rest. He reports cough productive of thick yellow-green sputum. D.Z. seems irritable and anxious; he complains of sleeping poorly and states that lately feels tired most of the time. His vital signs (VS) are 162/84, 124, 36, 102 F, SaO2 88%. His admitting diagnosis is an acute exacerbation of chronic emphysema.…

    • 1719 Words
    • 7 Pages
    Powerful Essays
  • Good Essays

    Chronic Obstructive Pulmonary Diseases (COPD) is a chronic inflammatory lung disease with no cure. COPD causes the lung to deteriorate which prevents breathing. People with this disease have cough, shortness of breath, damaged airways, chest infections and pain. These symptoms impair patients’ mobility and contribute to be housebound. Patients with COPD tolerate the burden of this disease for many years (6 years)6.…

    • 496 Words
    • 2 Pages
    Good Essays
  • Powerful Essays

    Clinical Notes

    • 963 Words
    • 4 Pages

    History of Present Illness: 64-year-old, well-nourished black male came in the office with chest pain for 2 days. Patient verbalized that he started having chest pain, especially when he is at work. He recently started a new job as a delivery driver where he is required to pick up and carry 50 pound boxes. He verbalized of generalized pain mostly in the chest area. He complains of pain 8 on a scale of 0-10. The pain is provoked with movement. Blood pressure was 154/90.…

    • 963 Words
    • 4 Pages
    Powerful Essays
  • Satisfactory Essays

    General Health: "I am very healthy, and feel that I am healthy as a horse."…

    • 671 Words
    • 3 Pages
    Satisfactory Essays
  • Better Essays

    Diversity Worksheet

    • 1955 Words
    • 8 Pages

    Answer the following questions in 100 to 200 words each. Provide citations for all the sources you use.…

    • 1955 Words
    • 8 Pages
    Better Essays
  • Better Essays

    Adult Health History

    • 3339 Words
    • 14 Pages

    |Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty |…

    • 3339 Words
    • 14 Pages
    Better Essays
  • Satisfactory Essays

    After getting diagnosed with anemia when she was 20, she started to include two raw eggs and one cooked egg in her daily diet.…

    • 356 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    Essay On Senior Living

    • 439 Words
    • 2 Pages

    According to the U.S. National Library of Medicine, Chronic Obstructive Pulmonary Disease (COPD) is a disease impacting the lungs, making it increasingly hard to breathe. The two main forms of COPD are chronic bronchitis and emphysema. The majority of people who suffer from COPD have a combination of both forms which leads to long-term coughing with excessive mucus and progressive lung damage.…

    • 439 Words
    • 2 Pages
    Good Essays
  • Better Essays

    Older Adult Assessment

    • 4088 Words
    • 17 Pages

    Source of history: the patient himself, seems reliable and his 31 year old son D.C. who also seems reliable and honest. M.C. and D.C. are both welcoming and willing to communicate; both give consistent and honest answers. No discrepancies or differences between the answers given. D.C. is helping interpret some of the more difficult words in the English language. M.C. understands English and can read and write at about the 6th grade level.…

    • 4088 Words
    • 17 Pages
    Better Essays
  • Better Essays

    Personal Impact Paper

    • 1549 Words
    • 7 Pages

    Chronic Obstructive Pulmonary Disease, is a Chronic and progressive illness that affects a person’s ability to breath. The affects to breathing occur due to obstructive airways caused by production of mucous from continuous inflammation and by constrictive airways caused by the narrowing of the bronchial tubes from spasms, scar tissue, reactive airways, infections of the lung, and the continuous response to irritating substances within the environment. Pollution, smoking, and other irritating substances cause the negative and damaging cascade of events that follow.…

    • 1549 Words
    • 7 Pages
    Better Essays
  • Powerful Essays

    4. Discuss the physical and psychological changes associated with normal ageing. How can one minimise pathological ageing?…

    • 1672 Words
    • 7 Pages
    Powerful Essays