Case Study On A Health Assessment Based On Subjective And Objective Data Collection

Introduction/Client Information

The purpose of this case study is to initiate the process of considering residents in a comprehensive and holistic fashion while maintaining professionalism through role-modeling. Also, to have the ability to make a health assessment based on subjective and objective data collection, and have the ability to make meaning from data collection and observations. In addition, I used Gordon’s Functional Health Patterns to assess my resident.

AS is a lively 98 year old, male at Weatherby Pavilion. Resident was born in England, and was working for British military force. Immigrated to Canada with wife in 1957, she passed away several years ago. The resident worked as an electrical contractor in Vancouver and ran his own business. Resident was admitted to due health issues and history of falls. Transferred from Yale Road Centre because, resident required residential care. Resident’s support system is his one and only daughter. Resident is diagnosed with colon cancer which is treated with a partial colectomy and colostomy, cancer of the prostate, coronary heart disease, congestive heart failure, atrial fibrillation, and basal cell carcinoma of left ear. Resident only uses hearing aid and no glasses. Currently on Furosemide, Metoprolol and Warfarin. Overall, resident is well and fully active. Physical Health and HistoryResidents vital signs were always in the same range as I noticed a pattern when I would take vitals every morning. Through a general observation by talking to my resident and observing I have noticed he is always present and conscious. Resident is always able to respond back to my questions; therefore I know he is fully alert and aware. AS is a pleasant man with no signs of any distress and he is in great health and is always cooperative and in a happy mood. After completing a head to toe assessment, he’s skin color looks normal, there no signs of any lesions. Has great posture and a good body build but is quite thin, has a steady gait but requires using a wheelchair/walker because of history of falls. Resident is always well dressed and groomed. He is always well kept and maintains good personal hygiene. In addition, my resident has no allergies or any infectious diseases and has never smoked or drank in his life. Family history is N/A because he lost all his family members during the war.

My resident has a history of medical issues. Resident was presented to Surrey Memorial Emergency following falls at home. Assessed in the hospital and found to have congestive heart failure with bilateral pleural effusions. This was treated conservatively and residents condition improved. Resident has coronary heart disease, specialist told him he would require a bypass but due to his age this was not recommended but treatment will be done with medications. Resident is diagnosed with atrial fibrillation in 2017 while admitted at Surrey Memorial Hospital. Presently is on warfarin, which is used to treat or prevent blood clots in veins or arteries, which can reduce the risk of stroke, heart attack, or other serious conditions. Resident is also currently on metoprolol, which is a beta blocker. It works by relaxing blood vessels and slowing heart rate, which improves blood flow and lowers blood pressure. Resident has past history of colon cancer with colectomy and colostomy approximately 10 years ago and carcinoma of the prostate treated with radiation approximately 30 years ago. Has had cataract repair and has basal cell carcinoma of left ear. Resident also presented with abnormal liver functions that were thought to be related to the congestive heart failure and passive congestion of the liver, it was deemed patient will require resident care so he was transferred to Yale Road Centre. Resident gets blood work done every week because he is on warfarin. International Normalized Ratio (INR) testing is well established as an integral part of warfarin treatment. INR has a critical role in maintaining the warfarin response within a therapeutic range, to provide the benefits of anticoagulation, while avoiding the risks of hemorrhage. Every week his INR levels come back high, normal range is 0. 8-1. 2 and resident always remains around 2. 1, therefore is important to take vitals every morning before giving him his medication. Recent x-rays (17/04/18) show a moderate sized left sided pleural effusion occupying approximately 30% of left hemi thorax. Small to moderate right sided effusion, occupying approximately 20% of the right hemi thorax. There's overlying atelectasis bilaterally. Due to his age no surgeries can be performed but can only be treated with medication. Recent ECG shows atrial fibrillation, low voltage QRS and abnormal ECG compared to ECG done 10/10/17, no significant change was found.

It is very important to consider these values because of all the heart conditions the resident has. Mental Health and HistoryA mental status examination (MSE) is an assessment of a patient's level of cognitive ability, appearance, emotional mood, and speech and thought patterns at the time of evaluation. It is one part of a full neurologic examination and includes the examiner's observations about the patient's attitude and cooperativeness as well as the patient's answers to specific questions.

The purpose of a mental status examination is to assess the presence and extent of a person's mental impairment. The cognitive functions that are measured during the MSE include the person's sense of time, place, and personal identity; memory; speech; general intellectual level; mathematical ability; insight or judgment; and reasoning or problem-solving ability. Complete MSEs are most commonly given to elderly people and to other patients being evaluated for dementia. The MSE is an important part of the differential diagnosis of dementia and other psychiatric symptoms or disorders. The MSE results may suggest specific areas for further testing or specific types of required tests. A mental status examination can also be given repeatedly to monitor or document changes in a patient's condition.

Mental Status Exam

AS, a 98-year-old Caucasian male, he was well dressed and alert on presentation to his room, he greeted me with a warm firm handshake. He was wearing clean, black hip protector pants, a buttoned dress shirt tucked into his pants, and black slippers and appeared slightly younger than his stated age. During the interview, he was pleased and attentive. He was very patient, playful and open while I was performing the exam and maintained good posture and eye contact, but would often go on a tangent when I asked certain questions and would get very emotional when talking about the war. He has a slow, steady gait but requires using a wheelchair/walker at all times to prevent any falls. Throughout the exam the resident had a good rate and flow of speech; he talked very clear and softly. Resident has great memory, he is able to recall all life events, family member names and where they live, and is orientated to time and place. Resident had logical and coherent thought patterns and is responsive to stimuli.

History of Hospitalizations

Resident has no past history of hospitalizations, expect when he fell at home and was admitted to Surrey Memorial Hospital. Stayed in SMH for a week to run some tests, then was admitted to Yale Road Centre and then to Weatherby Pavilion.

Care Plan

A nursing care plan is a process that comprises of properly identifying current needs, as well as identifying prospective needs or risks. Care plans also provide a means of communication between nurses, their patients, and other healthcare providers to accomplish health care outcomes. Without the planning process, quality and regularity inpatient care would be lost. Care plans include the interventions of the nurse to address the client’s nursing diagnoses and produce the desired outcomes. Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the foundation for providing the best patient care in nursing practice. In addition, resident has a high risk of fall because he tends not use to his walker/wheelchair; therefore there is a high emphasis on this nursing diagnosis in the care plan. In addition, while providing for my resident I intergraded RPN competencies into my care. I applied therapeutic communication strategies and techniques to reduce emotional distress when my resident would talk about the war. I did this through active listening, and therapeutic use of silence. I applied knowledge and application of conceptual nursing models, nursing skills, procedures and interventions which we learned in lab and communication class along with performing psychiatric assessments. I also established and maintained professional relationships that promoted client centered care, I did this through sharing information with the health care workers and being collaborative. I would collaborate with my resident to come up with ideas that could help advance their health and wellbeing, such as taking part in weekly exercises coordinated by the therapists. I also ensure I am engaging my resident in activities while maintaining client safety and providing quality care at the same time while adhering to psychiatric nursing code of ethics and standards of practice. I always try to engage resident to looking into resources that promote health such as sitting in on music therapy or taking part in balance class that is held every week.

Theoretical Model

The self-care deficit theory proposed by Orem is a combination of three theories, i. e. theory of self-care, theory of self-care deficit and the theory of nursing systems. In the theory of self-care, she explains self-care as the activities carried out by the individual to maintain their own health. Therapeutic self-care demand is the totality of the self-care measures required. The self-care is carried out to fulfill the self-care requisites. There are mainly 3 types of self-care requisites such as universal, developmental and health deviation self-care requisites. Whenever there is an inadequacy of any of these self-care requisite, the person will be in need of self-care or will have a deficit in self-care. The deficit is identified by the nurse through the thorough assessment of the patient. Once the need is identified, the nurse has to select required nursing systems to provide care: wholly compensatory, partly compensatory or supportive and educative system. The care will be provided according to the degree of deficit the patient is presenting with. Once the care is provided, the nursing activities and the use of the nursing systems are to be evaluated to get an idea about whether the mutually planned goals are met or not. Therefore, the theory could be successfully applied into the nursing practice. In addition, my resident has been taking care of his colostomy for 17 years without any help. Due to his age now he requires assistance from a LPN to maintain his colostomy. As a student nurse I can assist the LPN in helping maintain the colostomy by emptying out the pouch and assisting in applying a new one. By doing this I can also incorporate BPN philosophy such as providing care in a gentle, kind and professional manner.

Conclusion

In conclusion, my resident is an energetic and joyful individual who is diagnosed with cancer of the colon which is treated with partial colectomy and colostomy, cancer of the prostate which was treated with radiation, coronary heart disease, congestive heart failure, atrial fibrillation, cataract repair and basal cell carcinoma of left ear. Resident is very independent he can do everything own his on but requires assistance with maintaining colostomy. He is fully aware of his surroundings and responds back to every question you ask him. Overall, he is a well-kept and lively individual who was admitted due to history of falls and heart conditions.