Running head: ASSESSMENT OF THE OLDER ADULT 1

Assessment of the Older Adult

Ashley King

University of Saint Mary

ASSESSMENT OF THE OLDER ADULT 2

Abstract

D.K. is a 63 year old female. She lives in a home with her daughter and her daughters

family. She was diagnosed with HIV in 1994 and is taking medication to control her disease. She

does not work but stays active by running errands, cooking, cleaning, and spending time with

family. D.K. struggles with smoking cessation and sleeping. Due to her diagnosis of HIV she has

not been romantically involved since 2002 due to the loss of her husband to AIDs. An

assessment of D.K. and a plan is put into action below.

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Assessment

Introduction

The patient lives in a two-story home with her daughter, her son-in-law, and her two

teenage granddaughters. She has her own bedroom with the bathroom just across the hall. She

has lived here for a little over two years. The patient’s medical history includes being diagnosed

with HIV in 1994 and she also has chronic diarrhea that leads to weight loss and dehydration. As

of the patient’s last appointment with her infectious disease doctor, her viral load was

undetectable. The patient’s surgical history includes having six stents placed in her legs in 2011

and a hysterectomy in 1988. The patient also smokes at least a pack of cigarettes a day. She has

the ability to drive but does not own a vehicle so she uses family members when possible. She

cooks, goes shopping with her sisters, cleans, and walks around her neighborhood a lot. The

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

Physical Assessment

All of the patient’s senses appear to be intact. She has no trouble keeping her balance or

the feeling of pins and needles in her extremities. She does not report any changes in her hearing

and states she has worn reading glasses since her late 40s. The patient is very mobile and has no

problems getting around. She states she feels the best when she is getting up and around with her

sisters or other family members. Does not like doing nothing all day. She gets a lot of her daily

exercise by running errands, walking around malls, and going on brisk walks in the evenings.

The patient tends to eat out at restaurants a lot with her sisters and usually eats her leftovers for

dinner. She has a well-rounded appetite but does not eat big portions. She states she eats 6-8

times a day but small snack sized portions. She cooks most of the meals for the household. She

does state that she has cut back on her Coca-Cola intake from almost five per day to two per day.
ASSESSMENT OF THE OLDER ADULT 4

The patient is 4’11 and weighs 90 pounds which gives her a BMI of 18.2 meaning she is

underweight. The patient has always struggled with getting proper sleep. She has been on

Ambien to sleep for years. The Ambien makes her believe she is asleep but usually she is on the

phone with family members, smoking cigarettes in bed, and up walking around. She refuses to

get off of the Ambien but it imposes a huge safety concern that has been reiterated to her time

and time again.

Medications

The patient is currently taking Bayer 81mg for prevention of heart attack. Her HIV

antivirals are, Abacavir 600mg and Lamivudine 300mg which is also called Epzicom in

combination with another HIV antiviral, Kaletra 200-50mg. She also takes Zolpidem (Ambien)

10mg as stated above for her inability to sleep without medication assistance. The patient is

extremely compliant with her medications, especially her HIV antivirals. She has been on strict

medication compliance for over 20 years and has a system in place. She uses a Sunday through

Monday pill container and takes all of her medications at the same time every day. The HIV

medications can cause very serious hypersensitivity reactions but she states never having any

problems with her medications. The aspirin she is taking every day can increase her risk of

gastrointestinal bleeding. Although, she is very used to taking her medications she states that she

wishes she didn’t have to take so much medication every day.

Indoor Environment

The patient’s home is overall safe. All of the rooms are well kept and there is minimal

clutter. There are throw rugs on the hardwood floor and rugs for when you walk inside. There is

one smoke detector but unfortunately the batteries were dead so she wrote it down to make sure

she remember to replace them. There was no carbon monoxide detector that the patient was
ASSESSMENT OF THE OLDER ADULT 5

aware of. Almost every resident in the home smokes cigarettes and they do so in the garage

where they have multiple space heaters. This is a huge safety hazard due to the fact that the

smoke detector was also not working. The lighting in the house is appropriate. The patient has a

lamp on her bedside table for when she has to get up for the restroom in the middle of the night.

The household also has two indoor animals. Lilly, who is small Pomeranian and Pants, who is a

mid-sized orange cat. She loves having both of these animals company and Lilly even sleeps

with her.

Outdoor Environment

There are hand rails on the stairs that lead up to the front door, although the main

entrance the patient uses is the garage. The patient’s son-in-law maintains the outside very well

by mowing and landscaping all year round. The patient likes to help plant flowers in the summer

months to help with the landscaping. The son-in-law also shovels all of the snow when needed

for safer pathways. The backyard has a nice porch with only one step that leads to the grass area.

There is a tire swing and lounge area for entertainment but the back yard is not fenced in.

Patient Awareness of Safety Needs

The patient uses an iPhone and is very aware of how the basic things such as calling and

texting work. She has emergency contacts in her phone listed as “ICE” after their names. These

people include her daughter-in-law, son, daughter, and sisters. The patient states never putting a

plan in place for if a fire were to occur but that it was something that was important. The

bathroom she uses is very clean and well kept. There are no windows causing a draft while she is

bathing. There is no seat in the shower but that patient has no indication of needing a seat while

she showers. The bathing area does not have side rails and is also a tub shower that she states
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makes her nervous getting out of sometimes because she is so short and it can be slippery. The

toilet does have a rail by it but there is no raised seat which is also not a need for this patient.

Legal Protections

The patient does not have a living will, durable power of attorney, end of life plans or

funeral plans. The patient has always talked with her daughter-in-law about getting these things

in order, usually after someone in the family has passed away but has not stuck with it and got it

done. She knows she wants to be cremated like her late husband and to have her funeral services

at Maple Hill Cemetery. This funeral home holds a lot of her family and they let you pre-arrange

and pay payments. Her daughter-in-law has been pushing her to start the pre-arrange part but the

plans never falls through.

Financial Assessment

The patient states she is on Medicare and has supplemental insurance through Humana

Advantage. She also states that she has a co-pay for about six months that she meets and then

they pay the following six months. The patient states she is not aware about meeting the “donut

hole” and seemed very confused by the question. The patient’s only income is her late husband’s

social security disability check that she gets every month. Since her husband’s passing she has

always had to live with either her mom, a sister, or now her daughter due to her low income

status. Her family is very willing to help and she appreciates it a great deal. Her low income is

also the reason she does not have her own vehicle which can be frustrating for her. Her family

providing her with a place to live for free has really helped her save money and be financially

comfortable although she feels like a burden. When she was first diagnosed with HIV she got a

lot of support through the Ryan White foundation considering she was not working a well-paying

job with health insurance or being able to draw disability.

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Family/Community Support

The patient lives with quite a few people. She lives with her daughter, son-in-law, and

two granddaughters. Her sister that lives in Gardner, Kansas in a house on the lake has asked her

to come live with her multiple times. The household she is in right now has a lot of family drama

that she gets dragged into, that involves drugs and alcohol. She feels as if it is declining her

health to be in that situation. She does not consider herself a caregiver of anyone but she does

most of the cooking and cleaning while the other residents are at work. Her late husband passed

away in 2002 of AIDS and she has not been romantically involved since and states she does not

feel like she can be with her diagnosis. She still has friends from grade-school that she frequently

goes out with to do fun things such as getting their toes done, playing cards, and going out to eat.

She spends most of her time with her sisters. They love to go out to eat and have slumber parties

together. She has a ton of family support and people always checking up on her. She is not really

involved with her community or church. States she is not a very religious person but feels her

best when with family.

Plan of Care

This patient’s first nursing diagnosis is ineffective protection related to HIV as evidence

by weight loss (BMI), lack of sleep, and chronic diarrhea. There are some interventions that

could reduce or help to be aware of current infection. The first intervention for this patient is to

take their own temperature, pulse, and blood pressure every day to have their baseline. This

would help the patient be aware of changes in their vitals that could indicate infection or

bleeding. The second intervention would be to notify her health care provider promptly of any

signs of infection. These signs include fever, chills, edema, and pain. The third intervention is to
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avoid any invasive procedures, such as injections, catheterization, rectal or vaginal exam unless

absolutely necessary (Ackley, Ladwig, & Makic, 2011).

This patient’s second nursing diagnosis is disturbed body image related to HIV as

evidence by change in social involvement and fear of reaction by others. There are interventions

that could help the patient possibly overcome her diagnosis. The first intervention is to provide

the patient with appropriate community support groups, example in Appendix A. The second

intervention is to assess this patients level of social support. Social support is one of the

determinants of the patient’s recovery and emotional health. The last intervention is to assess for

lipodystrophy in the patient due to the fact that she is receiving antiretrovirals for her HIV

diagnosis (Ackley, Ladwig, & Makic, 2011).

This patient’s third nursing diagnosis is ineffective sexuality pattern related to HIV as

evidence by absence of significant other and fear of transmitting HIV. The first intervention

would be to explore her attitude about sexual intimacy and changed in her sexual patters. It is

important to understand the patient’s feeling. The second intervention is to encourage her to

communicate with potential partners in HIV prevention strategies. This is important so that the

patient understands she has options to be intimate again. The last intervention is to allow her to

verbalize her feelings about losing her sexual partner. This is necessary so the patient can get her

feelings out (Ackley, Ladwig, & Makic, 2011).

Conclusion

My patient having HIV puts her in the culture of being judged. Some people’s first

judgement of a person with HIV is that they are promiscuous or drug users. My patient has been

with one man in her entire life and never used intravenous drugs. She has been looked down on

and treated differently within healthcare. This makes her unwilling to go to the doctor when she
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should, which is completely unacceptable. I have first handedly experienced the judgement

passed on D.K. within health care and it is something I have learned from. D.K. shied away

when asked some questions but she got comfortable pretty quickly. Once she got started

speaking of her diagnosis, I could tell she needed someone to talk to with how much in depth she

went into it.

I felt prepared for this assessment due to being very involved previously in D.K.’s health.

I wish I would of came more prepared on insurance terms and background so I could of

understood that aspect more. Overall, the assessment went pretty well. I came over when

everyone in the household was at work so we could have some quiet and privacy. There were

minimal distractions; as in the television was on low volume and the animals were outside for the

time being. I went over my plan of care with D.K. even as personal as some of it was. She agreed

to everything and told me she would try her best to get back out there and keep taking care of

herself. I would not say I was surprised by anything, but this assessment and interaction will

tremendously help me throughout my nursing career. I am going to come across a lot of patients

with infectious disease such as HIV. This showed me how to ask the hard questions and to never

be judgmental.

The 5 C’s of caring applied to this assessment plan in many ways. Caring was applied

with the fact that this is someone close to me. I showed that I cared when speaking to D.K. to

show that I was not being judgmental of her situation. Competence was applied by thoroughly

completing this assessment in an organized fashion so that D.K. felt as if I knew what I was

doing, which she did. Confidence was applied in the fact that I knew the appropriate answers to

ask about her condition. Such as medications, viral load, and how she affords her care. I was

confident in the questions asked. Conscience is applied by not being judgmental by D.K.’s
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diagnosis of HIV. Giving her someone to talk to and not acting as if she is contagious or gross.

This is a very important C, that people tend to forget about. Compassion is applied by the fact

that I developed a plan of care for D.K. and went over it with her. I showed concern and a

willingness to help my patient.

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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.
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Appendix A

Visuals/Handouts

http://www.acphd.org/oaa/for-you/support-groups.aspx
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Appendix B
Assessment Project and Paper

Attach this grading rubric to the FRONT of your paper***

Evaluation Criteria for Assessment Project Paper

Name: ______Ashley King________________________

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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