Running head: ASSESSMENT OF THE OLDER ADULT AND CARE PLAN

Assessment of the Older Adult and Care Plan

Kendall Lillie

University of Saint Mary

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Abstract

B.B. is a 76-year-old female. She lives at home with her husband who is 79 and her two

dogs. She is still very active and works a few days a week as a nurse practitioner. Her health

history consists of hypertension, osteoarthritis, and hyperlipidemia. She is able to control these

disorders with medication. She also has restless leg syndrome that continues to interrupt her

sleep. Recently she is having increased trouble falling asleep and staying asleep. B.B. also has

trouble eating three meals a day due to her busy schedule. She often skips breakfast, eats a snack

for lunch, and has a decently large dinner. When she does eat, it is often something quick and

easy even though she knows it is not good for her. She seems to be at an increased level of stress

due to her busy schedule and the need to care for her husband.
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Assessment

Introduction

The patient lives in a three story house including a basement, main level, and an upstairs.

This house is located in Overland Park, KS and the client has lived there for over twenty years.

The client’s medical history includes hyperlipidemia, osteoarthritis, hypertension, and restless

leg syndrome. Her surgical history consists of an appendectomy, hysterectomy and a breast

biopsy that was negative. She also had an aneurysm that burst resulting in a subarachnoid

hemorrhage. However, they did not perform surgery and the bleeding stopped at its own. The

patient is able to drive, go grocery shopping, clean her house, and even work a few days a week.

The patient is very independent and does not use any assistive devices.

Physical Assessment

All of the patient’s sensory nerves appear to be intact. She does not complain of any

numbness or tingling and does not have any trouble with balance. She has noticed a decrease in

her ability to hear and always wears glasses or contacts. The patient is still very active both

physically and in her community. B.B. enjoys ballroom dancing with her husband and going on

walks when it is nice outside. They have exercise equipment in the basement and lots of room for

activities for the colder months of the year. She knows how important exercise is for her health

and tries to stay as active as she can. She loves to travel and her hobbies include gardening and

getting together with friends. However, her nutritional status could use improvement. She states

that it is often difficult to find time to eat three meals a day. This results in her skipping breakfast

and only eating a snack for lunch. When she does eat these meals it is often something quick and

easy instead of nutritious. She has not noticed a weight change but knows that this habit cannot

continue if she wants to live a healthy lifestyle. She also struggles with her sleep due to her
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restless leg syndrome. Often she finds it difficult to fall asleep and stay asleep throughout the

night. The patient also spends a lot of time taking care of her husband when he is sick. This can

create a strain on her physically and emotionally. However, she did not want to discuss this

aspect in detail during the interview.

Medications

B.B. is currently taking medication for all of her medical diagnoses. She takes Losartan

(Cozaar), an angiotensin receptor blocker, for her blood pressure. Rosuvastatin (Crestor) is taken

for her hyperlipidemia. She switches between Celecoxib (Celebrex) and Metaxalone to treat her

osteoarthritis pain. Pramipexole (Mirapex) is taken for her restless leg syndrome. She also takes

Omega-3 and a vitamin D supplement. The patient understands all the doses and why she is

taking these drugs. From the research I found, none of these drugs interfere with the action of

one another. Some of the serious potential risks from these medications include hypotension,

angioedema, rhabdomyolysis, MI, stroke, thrombosis, stevens-johnson syndrome.

Indoor Environment

The patient’s main level and basement has hardwood floors. She has a few area rugs but

they are mainly underneath furniture such as a couch or dinner room table. The upstairs is

carpeted and consists of all the bedrooms in the house. The kitchen is easily accessible and their

garage is connected to their house so they do not have to go outside. They have a bathroom on

every level which is extremely convenient. Their house is very kept and tidy. There was no

clutter and nothing to trip over. Their smoke and carbon monoxide detectors were working and

B.B. stated that they check them frequently and change the batteries when needed. They keep a

space heater in the basement but rarely use it. The general lighting in the house was very good.

B.B. had a few lamps but they were more for decoration than for use. The patient keeps her
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bathroom light on when she goes to sleep so she can see if she needs to get up in the middle of

the night.

Outdoor Environment

The house has a few steps leading to the front entrance which showcased a beautiful

garden of flowers and decorations. There are no handrails in the front to keep B.B. and her guests

from falling but she stated that she always kept them free of snow in the winter. The back of the

house has a large porch leading to an enormous backyard. However, the porch has a multitude of

steps that could potentially be hazardous. The grass is always mowed and they just put in a new

fence around their property. The land is very well kept and B.B. takes great pride in how

appealing her house is inside and out.

Patient Awareness of their own Safety Needs

The patient has a list of emergency phone numbers available in her cellphone. These

include an easy way to call 911 and her children on speed dial. She also carries an identification

card with a medication list and her medical history. The client knows to rescue herself and others

if they are in danger, then to contain the fire and extinguish it if possible. They keep a fire

extinguisher in their garage in case of emergency. The bathroom has a window but it is well

sealed and does not allow drafts. The shower stall has a built in seat so if she becomes fatigued

she has a place to rest. Her husband uses it frequently and they are glad they have it. The shower

also has a rail and a non-slip sticker that they added on their own. The toilet seat is at a standard

height but there is a rail on the wall in case they need assistance standing.

Legal Protections

The patient has both a living will and a durable power of attorney. B.B. is a full code and

wishes to be kept alive by whatever means necessary. Her husband is her durable power of
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attorney and she is his. She created a will a couple years ago after her aneurysm burst. The

patient has thought after end of life plans and wishes to be cremated.

Financial Assessment

B.B. has a Medicare advantage program for health insurance. They are able to meet

premiums and copays fairly easily since B.B. is still working and they saved a lot of money for

retirement. They do not have any trouble with their medication expenses. The patient does not

believe that their healthcare expenses affect their other life activities in any way. They are still

able to enjoy life and do the things they love such as traveling.

Family/Community Support

The patient lives with her husband and two dogs. B.B. sometimes has to assist her husband in

activities but for the most part they are each fairly independent. They have a lot of friends and

family and always have someone to call up if they want to do something. They get together with

their friend group at least once a month. During these events they drink wine, listen to music, and

talk to one another about their lives. B.B. and her husband are not part of a church congregation

and do not find religion to be an important part of life.

Plan of Care

The first diagnosis is readiness for enhanced nutrition related to need for improved

nutritional intake as evidence by verbalization of desire to change (Ackley, 2011) Interventions

for this diagnosis include recommending a guideline of food to eat, avoiding fast food, eating a

healthy breakfast every morning, and looking at food labels. The patient was given a handout

from ChooseMyPlate.gov (Appendix A). I educated the patient on ways to find time to eat such

as preparing healthy snacks beforehand, grabbing protein bars or low-fat yogurt, using an app to

grocery shop, and even using meal delivery services such as Blue Apron and HelloFresh.
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The next diagnosis is disturbed sleep pattern related to restless leg syndrome as

evidenced by leg discomfort during sleep relieved by frequent leg movement. (Ackley, 2011)

The book provided some interventions including pharmacological preferences such as melatonin

and non-pharmacological concepts like regular exercise, reducing caffeine, and exposure to

sunlight during the day (Eliopoulos, 2018, p.160-162). I also provided the patient with education

on seeing her doctor to determine if her dose of Mirapex should be adjusted. A visual was given

to the patient to emphasize some interventions that might be able to improve sleep (Appendix A).

The last diagnosis is risk for stress overload related to excessive stress as evidenced by

busy schedule and the need to care for spouse. (Ackley, 2011) Interventions include identifying

the cause of stress, altering those that are modifiable, and exploring therapeutic approaches to

resolve stress. A pamphlet was given to the patient on ways to reduce stress (Appendix A). I

educated the patient on the need to experiment with interventions to see what works for her.

Conclusion

My experience assessing B.B. was very beneficial for my learning. There were a few

culture differences that I noticed during my interaction. Asking B.B. these questions and hearing

her answers made me realize that we have both similarities and differences. For instance, we

both struggle finding time to do things such as eating three meals a day. However, I believe that

religion can have a strong impact on the health of an individual. We did the interview in her

living room and we sat face-face. The patient had an open posture and used eye contact to show

that she was interested and paying attention to what I was saying. I believe the “culture” of the

elderly differs among individuals. For the most part as we age our personality stays the same and

our culture beliefs do as well.

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I believe I was very prepared for the interview with B.B. I wrote down the questions in

my notebook and left enough room to write answers in the spaces. If I were to change anything

about my process, I would have asked if it would be okay to record the interview so I would not

miss anything. However, I just asked to clarify things as we went. There was not a TV running or

anyone else present but her dogs kept barking which disrupted the process. I think it would have

been beneficial to do the interview in a quieter place with less interruptions but I wanted to make

sure we did it in her natural environment. I was able to give some ideas on the spot about ways

she could improve her situations. I told her I would return with a plan of care and some visual

aids. I took my nursing diagnoses and interventions to her house a few days later and she was

very open to discussion. Since she is a nurse practitioner she told me that she had thought about

some of these before but some were new. She told me that she was excited to try some of these

out and hoped that they would work for her. I was not really surprised by anything throughout

this process just because I knew the patient fairly well beforehand. I do think this will help me in

my future career because a lot of patients are going to be a part of the aging community. This

interview and assessment allowed me to really connect with an older adult and ask the right

questions.

The five C’s of caring have been instilled in us since the beginning of nursing school. I

can recall these words like the back of my hand and try to exemplify them everyday of my life.

Compassion is critical in nursing and my assessment allowed me to connect with B.B. on a

deeper level to understand her situation better. I was also committed to my patient and wanted

the best for her in every way. I upheld my morals and showed conscience during my assessment.

Competence and confidence were both shown when I educated the patient on interventions

included in my plan of care.

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References

Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2011). Nursing Diagnosis Handbook: An evidence-

based guide to planning care (11th ed.). Place of publication not identified: Elsevier Mosby.

Eliopoulos, C. (2018) Gerontological Nursing. (9th ed.). Saint Louis: Mosby Elsevier.

HerbaZest. (2014, July 10). Did You Know: How to Get Better Sleep. Retrieved from

https://www.herbazest.com/community/did-you-know:-how-to-get-better-sleep

Marple, T. (2017, October 25). Exercise Reduces Stress -- Try These 4 Simple Actions. Retrieved

from https://www.intentio.com/exercise-reduces-stress/

USDA. (2018, June 27). ChooseMyPlate. Retrieved from https://www.choosemyplate.gov/

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Appendix A
Visuals/Handouts

https://www.choosemyplate.gov

https://www.herbazest.com/community/did-you- https://www.intentio.com/exercise-
know:-how-to-get-better-sleep reduces-stress/
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Appendix B
Assessment Project and Paper

Evaluation Criteria for Assessment Project Paper

Name: _____Kendall Lillie_______

Criteria Points Possible Points

Earned
Abstract stating accurately and concisely the content of the 5
paper. .
Introduction: Identifies the patient assessment. Include 5
overview of Assessment
Presentation of patient assessment: 5
Identifies all points required in assessment questions 5
Body of Paper: Shows a clear, concise and accurate 20
description uses care plan format in presentation of patient.
Writing Style of Paper: Continuity of thought in paper, 10
information presented in a clear and concise manner. Use of
grammar, punctuation, sentence structure. Paper written in
third person.
Professional Presentation: APA style, format, citations, 15
headings, margins, appendix, outline, etc.
Professional Presentation: Reference Sheet-Complete and in 15
APA format
Length: 5-8 full pages, including the title page, abstract, 5
references, and appendix.
Spelling and neatness 10
Submitted to Turnitin NLT 8/3– less than 25% similarity 5
index.
Total possible points 100
Submitted on time. 10% starting value deduction per day
late

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