Older Adult Assessment

NRSE 210
Older adult assessment: Part I
Subjective Data a. Biographic data

Name: M. C.
Address: 1257 Sunrise Lane Cheshire, CT 06410
Phone Number: (203) 898 – 7643
Age: 60
Birth date: February 27, 1953
Birthplace: Fuchou, China
Gender: Male
Marital status: Married
Race: Asian
Ethnicity:
Occupation: chef at a Chinese restaurant (China Dragon)
Primary Language: Chinese
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. b. Summary of Family history and genogram (attached)

Heart Disease: none Allergies: none
High blood pressure: mother, deceased (72) Asthma: none
Stroke: mother, deceased (72) Obesity: none
Diabetes: none Alcoholism or drug addiction: none
Blood disorders: none Mental illness: none
Breast/ovarian cancer: none Suicide: none
Cancer (other): brother, lung. Deceased (46) Seizure disorder: none
Sickle cell: none Kidney disease: none
Arthritis: none Tuberculosis: none

c. Review of systems and functional health assessment:

1. Health Perception – health management: General Health: Patient states he feels generally healthy, only concern is his current, peristent cough that has been bothering him for the past couple of months. Pt relates the cough to his use of smoking tobacco, smokes approximately half a pack (10-12 cigarettes every day) M.C. states that he has been smoking for the past 35 years.

Past illness: Patient denies any past illness

Chronic illness: patient reports no past chronic illness

Operations: Patient states he had a hernia operation when he was 15 years old on the left side done in Fuchou, China

Accidents: Patient denies any accidents

Hospitalizations: Patient states no past hospitalization, hernia procedure was outpatient, only stayed in hospital for less than 24 hours.

Health Promotion activities: patient cannot recall any health promotion activities, says he only takes one multivitamin pill every day

Allergies: patient denies having any allergies

Perception of health: M.C. states his perception of his self health is generally in good condition and that he has no problems besides the current cough he is experiencing. Defines health as “being in a state free of infection or illness, being happy and stress-free”

2. Nutrition/Metabolic

Skin: M.C. states no history of skin disease, no eczema, no psoriasis and no hives, states he has no current problems with his skin. M.C. denies lesions, pigment change, and excessive dryness and moisture. M.C. moisturizes skin daily with over the counter moisturizer.

Hair: M.C. states no recent loss of hair or change in texture. Pt states hair is “graying” changing color from mostly black shifting over to more gray hair. M.C. says he gets monthly haircuts (son cuts his hair)

Nails: M.C. denies change in shape, no color change and no brittleness of his nails.

Mouth and throat: M.C. reports no past history of mouth pain, bleeding gums toothaches or lesions in the mouth. Pt denies history of sore throats, dysphagia, tonsillectomy or altered taste.

Neck: M.C. denies neck pain. No limitations in motion, lumps or swelling. No enlarged or tender nodes, no goiter.

Daily food intake: Pt recalls a daily food intake of consuming rice, fish, vegetables, and meats. M.C. says he follows a special Chinese diet, eats Chinese cultural dishes often with large quantities of soy sauce. M.C. admits his diet is high in sodium content

Supplements, vitamins, herbs: M.C. states he takes one multivitamin pill with a meal every day during lunch.

Fluid intake: M.C. states he keeps hydrated by drinking diet pepsi soda, minimum water intake (about 2-3 glasses/day).

Recent weight loss/gain: Pt recalls a steady gradual increase in weight over the past six months (gain of about 8 pounds)

Dental: M.C. states that his last dental checkup was in March of 2011. (M.C. does not go to the dentist yearly). Patient has three upper teeth missing and two lower molar teeth missing (fallen out) M.C. also states having two crowns in his upper teeth. Pt believes it has resulted from a lack of brushing his teeth during his teenage and early adulthood years (brushed once a day during his 20s-30s) Pt. now brushes 2x/day, does not use floss or rinse with Listerine.

3. Elimination

Abdominal: M.C. reports no abdominal pain, no food intolerances or abnormalities with appetite associated with eating. Pt denies any abdominal disease, no ulcer, jaundice, appendicitis or colitis.

Gastrointestinal: patient denies nausea or vomiting, history of vomiting blood. M.C. states flatulence is normal after meals, frequency of bowl movement occurs during the morning right after breakfast and before dinner every day. M.C. denies recent change in stool characteristics, no constipation. No hemorrhoids, no fistula.

Urinary System: M.C. denies history of urinary disease, no past kidney disease. Frequency of urination is five to seven times daily with no pain or other abnormalities during urination. M.C. denies nocturia, dysuria, polyuria or oliguria, no kidney stones, no urinary tract infections.

Drains, ostomies: M.C. denies having any drains or ostomies. 4. Activity/ Exercise

Respiratory: M.C. reports having only difficulty breathing at times (shortness of breath) as a result of his coughing episodes, this has lasted for the past two weeks. Besides the cough pt reports no problems or abnormalities with respiratory system. States no past history of lung diseases, no asthma, no emphysema, no tuberculosis. Last chest x-ray was taken in 2008 (negative) TB skin test was negative, also in 2008.

Cardiovascular: M.C. reports no problems with cardiovascular system. Pt reports no precordial or retrosternal pain. Pt denies cyanosis, no hypertension, no coronary artery disease, or anemia. M.C. reports no past hisrory of ECG or other heart tests or cholesterol screening.

Musculo-skeletal: M.C. reports no history of having gout or arthritis, no past or present joint pain, stiffness or swelling. M.C. reports no muscle pains, cramps, or weaknesses and states he has no difficulties with coordinated activities. M.C. states he has no past or present back pain, no limitation of motion, and no past history of back disease.

Peripheral Vascular: M.C. states no past or present history of coldness, numbing, tingling or swelling of the legs. Pt denies discoloration in hands or feet. M.C. denies any peripheral vascular problems, no varicose veins, no intermittent claudication, no ulcers.

The Lawton Instrument Activities of Daily Living: Patient scored 8/8 total points, patient seems to be able to handle tasks fairly easily on his own with no assistance from family members. Patient states he performs all these tasks on a regular basis with no problems. Patient indicates a high level of independence.

Exercise: M.C. states that he only received exercise while working in the restaurant in extremely hot conditions from the grills and flames used to cook the buffet food. He cooks for 10 hours a day and says it’s a grueling job and that he is sweating and has to take a break every couple of hours to catch his breath and rest. Besides working in the restaurant patient receives no additional forms of exercise

Leisure activities: For leisure M.C. says he likes to go gambling at Mohegan Sun or Foxwoods casinos (about once a week) with his wife, son and daughter.

Pain: M.C. states there is no pain associated with him working or performing activities of daily living

5. Sleep/rest

Number of hours of sleep, naps: M.C. receives seven hours of interrupted sleep per night, states he takes two to three naps ranging from 15-30 minutes during the work hours of noon- 10pm Monday- Sunday. States sleep in interrupted by coughing.
Dreams, nightmares, sleep walking: M.C. states dreams are usual and random, sometimes see’s his family members who are still living in China in his dreams, has no nightmares, and does not experience sleep walking

Sleep aids: M.C. says he does not use any sleep aids

6. Cognitive/ Perceptual:

Eyes: M.C. denies difficulty with his vision, states he has no decreased acuity, no blurring, and no blind spots. Pt states he has no eye pain, no redness or swelling, no watering and no discharge. Denies other vision problems: no diplopia, no glaucoma, no cataracts. M.C. says he does not have prescription glasses, but he does have a pair of reading glasses for reading the newspaper. M.C. does not recall his last vision check, and he states he never got glaucoma tested in the past.

Ears: M.C. reports no history of earaches, no ear infections and no discharge. M.C. states no past or present tinnitus, no vertigo. M.C. says for his method of cleaning ears he uses a Q-tip to clean accumulated cerumen on the outside of his ear canals.

Neuro: M.C. denies past history of seizure disorders, strokes, fainting, and blackouts. M.C. denies weakness or coordination problems in his motor function, denies numbness and tingling in his sensory function, no past or present memory disorders in his cognitive function. M.C. states he does not have nervousness, denies history of mental health dysfunction or hallucinations, no depression, no mood changes.

Hearing: M.C. denies any problems or changes in hearing, states he does not have any hearing aids.

Language/speech: M.C. says he believes his language and speech are advanced in Chinese and that he has no difficulty with his speech and language with his native language. He believes that his English however may be hard to understand to the people that he is talking to in the restaurant he works at because he says he speaks with a thick, heavy accent.

Memory: M.C. and his son D.C. state memory is great and that M.C. can recall a lot of information with no loss of memory or any memory related problems.

7. Self- perception/Self concept

View of self: M.C. views himself as “generally healthy both physically and mentally”. He says he is happy with his health and he is happy that he is living with his family. M.C. states he believes he is a good guy who is always willing to help others with a problem or just be there to support others. M.C. says one of his self-concepts he has is his interest in helping others with their problems and being friendly and outgoing with whoever he associates with. M.C.’s son D.C. says that M.C. is mentally and emotionally sharp and he loves to be there for his family to support them.

Fears/Anxieties: M.C. verbalizes no past or present fears or anxieties, says he cannot recall a past or present fear or anxiety.

Hopes: M.C. states that his hopes in life are to continue to have a close relationship with his family, to be rich and to be successful. 8. Role-Relationship

Family structure: M.C. lives with his wife and son and daughter. M.C.’s son has two young boys (1/2 and 7) and his daughter has one young boy aged 5. Everyone lives together, including M.C.’s 54 year old brother.

Living arrangements: M.C. says he lives in an extended family environment at home and that it is common in Chinese culture to live in larger extended families especially with more members of the family present. He lives with his son, his daughter, both of their children, his wife and his brother. M.C. says they all live in a 5 bedroom house that accommodates them well for their family size.

Roles: M.C. is known as the “head of the household” and makes most of the family’s financial and economical decisions, especially decisions made at the family restaurant (China Dragon). He states he also has the roles of being a father, a son to his father and mother who passed away, a brother to his 54 year old brother Z.C., and a grandfather to his son and daughter’s children.

Occupation/work/school: M.C. works at China Dragon, a Chinese buffet style restaurant in Cheshire, CT. M.C.’s occupation there is the head chef. M.C. states he finished with a degree in business in a Chinese university in Fuchou, and that he has not gone to school in the United States.

Health insurance/finances: M.C. says he does not have health insurance, states “he never needed it” but mentions that if a circumstance were to arise where he needs to go to a health care provider he has the financial stability to cover any medical expenses.

9. Sexuality/Reproductive

Sexual relations/concerns: M.C. reports of no longer engaging in any sexual relations or sexual interactions with his wife. M.C. does not express any concern over this, states that this is common in his Asian culture to stop having sexual relations after a certain number of desired pregnancies and births.

Male history/prostate issues: M.C. states his prostate has always been healthy, has never experienced any prostate issues. M.C. denies penis/testicular pain, no abnormalities with his prostate/male genitalia. No lumps, no hernia, no sores or lesions, no penile discharge. M.C. states he does not perform testicular self-examinations.

10. Coping/Stress/Tolerance:

Recent changes: M.C. does not recall any recent changes in stress.

Crises: M.C. states that he always worries about making money and wants to always make more, find more ways to increase his restaurant business and expand to maybe another future buffet sometime in the near future.

Use of substances: M.C. says he is a smoker and that he smokes about half a pack of cigarettes every day. M.C. does not consume any alcohol and does not report using any drugs or mind altering substances.

Coping and stress managing strategies: M.C. states he uses cigarette smoking to cope with the financial stress and desire to make more money, resulting in smoking 10-12 cigarettes per day (half a pack). M.C. says that he has a desire to someday quit smoking, however he has not been contemplated making this change recently. M.C. states he believes he can quit smoking someday, but has not given it any serious thought.

Perception of stress tolerance: M.C. states that he has a good tolerance for his levels of stress and that he can handle different situations and get them under control. 11. Values/Beliefs

Religious choice: M.C. states he does not affiliate with any religions but he and his family do practice some Buddhism

Spiritual beliefs: M.C. states he believes in reincarnation and that you will be born and rise again after death

Attainment of life goals: M.C. says his attainment of life goals is to become successful and to stay happy with his family

Cultural beliefs/practices: M.C. states he does not have any other cultural beliefs and does not engage in other practices affiliated with culture or religion.

Holiday Celebrations: M.C. says he celebrates China’s largest celebration with his family the Chinese New Year, which starts on New Year’s Eve day December 31st, and runs to the 15th day of the first month in January. He says this is China’s largest and longest celebrations. M.C. and his family celebrate by cooking a lot of seafood and giving each other gifts and money.

Part III Analysis of Data

A M.C. is a 60 year old male who resides in Cheshire, CT and works as a chef at his Chinese restaurant. He considers himself as generally healthy, with the only concern of having a current cough that he is experiencing. M.C. complains of difficulty with his breathing at times with a shortness of breath that results in episodes of coughing. M.C. states the cough has been persistent for the past couple of months. M.C. states that these coughing episodes produce a persistent, dry cough that is nonproductive. He states that the coughing is generally aggravated or made worse after smoking. M.C. explains that he smokes half a pack of cigarettes every day (about 10-12 cigarettes) and that he has smoked for the past 35 years. M.C. complains that the coughing has resulted in interrupted sleep and that he wakes up in the middle of the night. As a result of this, M.C. says he receives about seven hours of sleep that is often interrupted. M.C. also states that to cope with stress he often turns to smoking. He uses smoking as an escape from his stressors at work and states that it often gets him fatigued from the long working hours. For a family history, M.C.’s mother passed away with a stroke at the age of 72, who also had high blood pressure. M.C.’s bother passed away of lung cancer at the age of 46. For objective data M.C. had normal breath sounds during the physical exam; however the breathing sounds were often interrupted by a dry, nonproductive cough during auscultation of the lungs. M.C. appears well nourished with no physical deformities. He is 5’8” and weighs 180 lbs, putting him in the BMI range of approximately 27.37 (overweight). M.C.’s right arm blood pressure is 130/86 and his left arm blood pressure is 126/84 (pre hypertension). During the physical exam M.C.’s breathing sounds were normal with no adventitious sounds; however, his breathing was often interrupted by a dry non-productive cough which resulted in a shortness of breath.
B
The nursing diagnosis chosen for M.C. is “impaired gas exchange related to smoking as evidenced by persistent cough that has lasted for the past couple of months and shortness of breath”. This diagnosis was chosen because I feel like it deserves the most attention especially since the patient is experiencing shortness of breath. This diagnosis was also chosen because the patient M.C. states that he has been smoking for the past 35 years. I feel that this diagnosis is the most important one to focus on this patient because M.C. had interrupted breathing sounds during the physical exam that resulted in shortness of breath. Difficulty breathing and other airway related troubles should be the highest priority in a patient, especially because it can be life threatening if the coughing and shortness of breathing persist. M.C. has been smoking for the past 35 years which is a sedative lifestyle risk factor that puts him at risk for lung cancer and other breathing related problems such as asthma, chronic obstructive pulmonary disease (COPD), heart disease, and stroke.
C
One measurable goal for my patient M.C. to achieve relating to my diagnosis is being able to transition M.C. from the pre-contemplation stage to the contemplation stage of quitting smoking. The nursing measureable goal is “by next month’s follow-up appointment, the patient will verbalize showing an interest in contemplating a reduction or cessation in smoking”.
D
The intervention plan for my patient would be focused on education. I would explain the benefits of quitting smoking to M.C. and give factual information that would give M.C. the opportunity to possibly change his mind about his smoking habits and hopefully as a result transition him from being in the pre-contemplation stage to the contemplation stage of smoking cessation or reduction. I would first explain to M.C. the advantages to cutting back on smoking and encourage him that most people who reduce their smoking have a much greater chance at quitting unexpectedly altogether. In the Nicotine and Tobacco Research review article published by John Hughes M.D., a professor at the University of Vermont explains that according to a qualitative review “of 19 studies on smoking reduction in individuals who did not want to quit, this method, typically coupled with the use of nicotine replacement products, led to an increase in quitting in 16 of the studies”(Science Daily). Providing M.C. with this information can give him the opportunity to consider the idea of quitting smoking, especially if a nicotine replacement product is recommended to him such as a nicotine patch or nicotine chewing gum. I would provide educational pamphlets and handouts to M.C. both in English and Chinese so M.C. will know what changes to expect when reducing or ceasing his smoking. Another way to help M.C. reach the goal of transitioning from the pre-contemplation to the contemplation stage is by providing M.C. with effective benefits and reasons to cutting back on smoking. By telling M.C. that even the slightest reduction of smoking can help reduce the risk for heart attack, stroke and cancers can hopefully catch M.C.’s interests in preventing these health risks from occurring. Explaining the short term benefits of smoking reduction such as the ability of the lungs to clear up and repair themselves can influence M.C. in contemplating smoking reduction. This could be used as motivation to think about quitting or reducing smoking because M.C. has been concerned over the persistent cough that has been bothering him for the past two months. Explaining how the body reacts to reducing smoking is important to explain to M.C. such as “Withdrawal symptoms usually occur within 24 hours of stopping smoking or reducing the number of cigarettes smoked per day. These symptoms are signs that the body is recovering from smoking”(NHLIB). Explaining this to M.C. is important in order for him to know what will happen during this process. I would back this statement up by explaining that a smoking reduction or cessation will give M.C. more stamina in walking and doing daily activities of living, and most importantly result in a reduction in coughing as the lungs begin to clear up. Encouraging M.C. to engage in alternative activities such as getting some physical exercise would distract M.C. and reduce his urge to smoke a cigarette and help him clear up his lungs and improve his breathing. E To evaluate my intervention I would follow up with M.C. and get in touch with him on a weekly basis to see if any progression has been made. I would get in touch via telephone with M.C. to track his progress. I would also recommend M.C. uses a journal to document his feelings and if any he reduced the amount of cigarettes he smoked on a weekly basis. I would encourage M.C. to visit for bi-weekly checkups to check on his vital signs, including checking blood pressure and doing an auscultation of his lungs to see if M.C.’s coughing episodes have gotten better. This will allow to for me to see if his lungs are cleaning up and further encourage M.C. to make every effort that he can to reduce his smoking. I will know if my goal has been met by M.C. verbalizing that he decreased his smoking by half from smoking 10-12 cigarettes a day to 5-6 cigarettes per day. Another way I could would be able to tell if my goal of M.C. transitioning from the pre-contemplation stage to the contemplation stage in smoking reduction is M.C. stating that he had purchased nicotine replacement products like nicotine patch and nicotine gum. This would show me that M.C. is seeking other possible alternatives instead of turning to smoking. M.C. verbalizing an interest in quitting smoking would result in this goal being successful because this would mean that M.C. has gone from the pre-contemplation stage of not thinking about quitting, to the contemplation stage where he is seriously considering in making a commitment to reduce or stop his smoking.

References University of Vermont (2006, December 8). Not Ready To Quit? Try Cutting Back – Smoking Reduction May Lead To Unexpected Quitting. Science Daily. Retrieved June 18, 2013, from http://www.sciencedaily.com/releases/2006/12/061207160012.htm "Nurses: Help Your Patients Stop Smoking." Www.nhlib.gov. National Heart Lung and Blood Institute, Web. 18 June 2013. http://www.nhlbi.nih.gov/health/prof/lung/other/nurssmok.txt

References: University of Vermont (2006, December 8). Not Ready To Quit? Try Cutting Back – Smoking Reduction May Lead To Unexpected Quitting. Science Daily. Retrieved June 18, 2013, from http://www.sciencedaily.com/releases/2006/12/061207160012.htm "Nurses: Help Your Patients Stop Smoking." Www.nhlib.gov. National Heart Lung and Blood Institute, Web. 18 June 2013. http://www.nhlbi.nih.gov/health/prof/lung/other/nurssmok.txt