Health History and Screening Older Adult

S.P. is admitted to the orthopedic ward. She has fallen at home and she has sustained an intracapsular fracture of the hip at the femoral neck. The following history is obtained from her: She is a 75-year-old widow with three children living nearby. Her father died of cancer at age 62; mother died of heart failure at age 79. Her height is 5’3 and weighs 118 pounds. She has a 50 pack year smoking history and denies alcohol use. She has severe Rheumatoid Arthritis (RA) and had an upper GI bleed in 1993 and had Coronary Artery Disease with CABG 9 months ago. Since that time, she has engaged in “very mild exercise at home.” Vital signs are 128/60, 98, 14, 99 degree farenheight (32.7 degrees C) SAO2 94%

Mr.’s Jones suffers from the following symptoms, painful joints particularly her knee, and hip, fingers and back, joint stiffness, limited joint movement and swollen feet and enlarged joints. These symptoms are due to significant problems with Rheumatoid Arthritis (RA) and Osteoarthritis (OA).

No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,

I arrived to work well rested and ready to start the day. I had just returned after a two week long vacation. Because of the time off, I arrived to 7 East to find that the assortment of patients was not familiar at all. As I began getting reports on my patients, one in particular I started to feel a little anxious and stressed. At first glance I could tell I would be busy for the next twelve hours. Lynda was a 45 year old woman that was admitted almost a week ago after having an emergent tracheostomy placed. Lynda was newly diagnosed with laryngeal cancer with already having several other diagnoses including: seizure disorders, mild mental retardation, behavioral issues, and was legally

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The general head to toe assessment is very important because it assess the overall physical condition and status of EM. I checked the most common part of the body that are susceptible to infection like the skin because of pressure ulcers. Checking the cardiovascular like pressing nail beds,

Mrs. H. 43 –year- old African American female, elementary school teacher, a single mother with two kids 5 and 8 years old girls with no significant past medical history admitted on emergency room at 4:35 p.m. Her appearance was tidy, stylish and scented. She was capable of provide information. She was able to speak clearly, conscious, and coherent also she was oriented to time, place and person. She complained of a cough with whitish mucus that sometimes it ends up vomiting. She suffered chest pain and worsening dyspnea for 1 week. She stated restlessness all night and weight loss about 5 lb. during last week. She explained her worsening pain make her unable speak; she felt suffocated with shortness of breath that

A head to toe assessment is the visual and manual inspection of each body part starting at the head and scalp and continuing downward to the feet and toes. These four techniques will be used: Inspection=what can be seen, Palpation=what can be felt, Percussion=what can be heard and Auscultation=what can be heard using a stethoscope. It is very important to perform a complete head to toe assessment on all patients at the beginning of the shift as this information will help determine if the patient is getting worse or starts having any unforeseen problems.

In the case of Anne Morrell there are several normal physiologically changes that impact her quality of life. Anne is experiencing normal aging related changes to her musculoskeletal system. Changes in musculoskeletal tissue occur through the loss of muscle mass and strength which replace lean body mass which fat and fibrous tissue. These changes in tissue cause a decrease in contractile muscle force with increased weakness and fatigue (Boltz, Capezuti, Fulmer, & Zwicker, 2012). As discussed in her case study she reports back pain when standing or walking for longer than 15 minutes, needs assistance with steps, ambulates with a cane since she fell last year which affects her mobility and ability to perform her activities of daily living. This loss in Anne’s muscle function greatly increases her chance of falls and she also has an increased risk for disability.

The aging process has a negative impact on the musculoskeletal system. During the aging process bone density and mass decreases resulting in high risk for fractures and falls. Muscles lose their mass, bulk, and tone which causes weakness. Abnormalities of this system along with pain affects activities of daily living. Some questions that may be asked during this assessment are; Have you had previous joint, muscle or bone problem? Does joint, muscle or bone problem affect your daily activity? Do you have pain? (if yes) Where do you have pain? What aggravates the pain? Have you had any surgery? Pertinent assessment for this patient are postural abnormality, limited range of motion, gait, and balance. The patient is observed laterally and posteriorly

The patient states that he can only walk for a few minutes and then his buttocks start hurting him and he has to stop, which suggests spinal stenosis per physician. He has numbness along the feet which could also be due to some neuropathy. The patient had MRI in 2014. The patient does have a hot and cold wrap and a two-lead transcutaneous electrical nerve stimulator unit. The patient does need a back brace. He does have a neck pillow, as well as neck traction kit. Chores are not being done. Lifting is curtailed to less than 25 pounds. The patient is sitting most of the time around the house. He is standing and walking no more than few minutes at a time.

If she takes the test and finds out that she doesn’t have the lung disease, there’s nothing lost, but if she does then there is a preventative care. Lifestyle changes that can be made include altering eating, exercise, or general lifestyle habits. With technological advances and knowledge of new treatments the benefits of knowing outweigh the negative possibilities.

I interviewed a 75 year old female. She suffers from arthritis on her hips, high blood pressure and has thyroid problems. When she was younger she use to do aerobics and danced with no problems. Now, due to having arthritis on her hips she cannot bend down for a specific period of time or dance as much as she used to. Twenty years ago she danced all the time, and got involved in physical activities like aerobics. Ten years ago she was still able to do things around the house, dance with no problems and still do aerobics. Five years ago she was still able to do physical activities until recently when she was diagnosed with arthritis on her hips. She takes medications for her arthritis, thyroid problems, high blood pressure, and aspirin for better

The health of our eyes, ears, and throat is very essential to our overall health. As part of a complete assessment, it is important for the nurse to assess these organs. These organs go through essential changes throughout the human life span. The nurse should be aware of these changes as she performs her assessment. In this discussion post, I am going to compare and contrast the age variation with an assessment of the eye, ear, and throat.

H.L. is a 72 year old Caucasian female that is here for a follow up from her annual screenings. She was a new patient of this facility at the end of last year, and she came for her annual two weeks ago. She complained of feeling fatigue and having low energy levels but was going to make some lifestyle changes first to try to improve this. She reports today that she sleeps all the time and has no desire to exercise. When she tries to exercise, she reports that she feels weak. Ever since she fractured her ankle at Christmas from stepping out of the truck, she has pain in that foot as well with activity. She went to the urgent care place in December, and she reports that they suspected a fracture. However, she never followed up with the x-ray ordered or MD appointment regarding this, other than her annual physical. She reports that she has been constantly losing weight but is not trying to. Her calcium, CBC, CMP, TSH, lipid panel, PTH, ALP, and Vitamin B 12 were all normal. Vitamin D levels were slightly low in the past, but not severe. Her mammogram, colonoscopy, and skin exam by dermatology came back clear that was ordered at her annual. She has a history of hypertension, allergic rhinitis, hyperlipidemia, osteoarthritis, controlled depression, and recurrent UTIs. She has a surgical history of a precancerous mole removed years ago, hysterectomy, and she was hospitalized with pneumonia three years ago.