Comprehensive Gerontological Assessment Paper Example

Introduction

To develop a thorough care plan for patients across all ages, it is essential to conduct a comprehensive gerontological assessment. Aged patients in particular usually require an in-depth assessment which requires more time and adequate breaks. The assessment for this assignment was conducted on an older adult who was aware of the purpose of the interview which was for learning purpose rather than serious therapeutic assessment. The interviewee was aware that the information provided would be shared only between the tutor and the interviewee while their identity will remain private.

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Client Profile/ Biographic Data

For this assessment, a woman born on April 4th, 1950 was interviewed. She is per the time of assessment 68 years in age. The man is black by race and by an observation she is stable and is alert to place, person, time, and even familiar with the current situation. The client was staying in a small African village of Ndanda, Tanzania where is her place of birth. She thereafter moved to the United States and currently lives in the city of Charlotte.

Family Profile

The patient is not married and used to live with her mother who passed away eight years back. Currently, she is living alone since she has no children or grandchildren. She lives close to her two brothers and their families who are helpful and supportive. They equally play caregiving roles to the patient. Additional to the family support, there is a caregiver who stays with him during the weekdays. While interviewing the patient, it was possible to determine that she feels supported by her brothers and their families. The family APGAR tool of assessment is useful is useful in the description of the socio-demographic profile of aged patients with chronic sickness regarding family support (Hudson, et al., 2010). The patient APGAR score was 9 reflecting a higher functionality in her family support.

Living Environment

The client lives privately in her own home though close to her two brothers and their families. Her house has almost all the requirements including bathroom, toilet, kitchen, living area, and lounge. All the rooms in her house are handicap accessible. During the assessment, an evaluation of her house was conducted, and it was determined that her living conditions are safe. The environment is clean and provides for all of her needs. There were no abnormalities associated with the living environment.

Recreational/Leisure Activities

Usually, leisure and recreational activities change as a person as a person ages since they no longer have the derive and function they had when younger. The patient assessed mentioned she has realized that her age does not allow her to move outside the house often. For recreation, she mentioned enjoying visiting her brothers' families, going to shop and playing with her brother' siblings. There was no abnormal discovery with the patient's leisure activities considering old people tend to be less active.

Resources/Support System Used

Elderly patients usually suffer from mental problems such as poor recall of information hence hard to assess them. Considering the patient assessed here, she was alert and provided a thorough history of her life. She was initially employed and had retired nine years ago. She knows all about her medication and her brothers provide for her medical needs.

Description of Typical Day

According to Graf (2008), considering the daily routine can be significant on some patients for a more exhaustive geriatric assessment. For the patient assessed here, the daily routine was not that important considering her sound mind. Nonetheless, she reported different daily routines with consistency in some parts. The patients wake up around six in the morning, showers, eats breakfast and watches tv with snacking in between until dinner then sleep. The only irregularity in this routine is her numerous insomnia episodes as a result of anxiety.

Present Health Status

It can be assumed that the patient is in good health for her age. She is currently feeling normal despite suffering from polio which was diagnosed when she was for years old. As a result of polio, the patient occasionally suffers from back pain, arthritis, and joint pains. Otherwise, the patient manages her health well and has recently taken colonoscopy, mammography, pap smear, and lipid tests. Also, she has taken immunization vaccines on tetanus, influenza, pneumonia, and shingles.

Medications

Polypharmacy can be a common problem for older adults especially when studies show that about more than half of people aged above 65 years taking five or more medications weekly (Sergi, De Rui, Sarti, & Manzato). This client takes four oral medications daily. Her medication needs list includes 40 mg of omeprazole, 5 mg of lisinopril, 40 mg of atorvastatin and multivitamin pills. The client controls her medication well and administers them to herself. Considering her condition, it is clear that she needs these medications. In addition, there is no risk of polypharmacy that her medication can bring.

Allergies

The client does not report any form of food allergies but does report an allergy to sulfa and penicillin. The symptoms the client gets from these substances is vomiting and nausea which is considered as true effects of allergy. However, she only realized these effects in her childhood and since then has never used these substances hence not sure what effects they can have now.

Nutrition

Nutrition plays a vital role in older adults considering that they have decreased appetite and thirst sensation (Suominen, Sandelin, Soini, & Pitkala, 2009). To come up with a care plan, it is essential to provide a thorough nutrition assessment. The client assessed reports a decrease in appetite and thus uses multivitamins to boost her appetite. To check her nutritional status, the Mini Nutritional Assessment Tool was used. The patient scored 13 meaning that her nutrition is on normal status.

Past Health Status

The patient does not have any recent hospitalizations. She cannot remember the last time she was hospitalized since she never experiences serious illnesses. Her past medical history includes the treatment of polio which she has experienced her entire, and anxiety that she now controls without medication. Although there are other health problems she experiences, most are controlled by medication and monitoring.

Family History

This patient had no information about her family health background and cannot recall much of the conditions her father or mother suffered from. Her brothers could have assisted here, but they were unavailable when the assessment was being conducted.

Review of Symptoms

Present health status includes the complaints the client gave an observation of her condition. Her skin looks normal for her age, and there were no open wounds or brises. The patient complained of joint and muscle pains, but this is due to her bound-on wheelchair. There were no abnormal things that were observed from the patient. The patient was alert to pace, person and time showing that she is neurologically intact. Along with the orientation question, the Mini-Cog screening tool was used to assess her mental status. Administered in five minutes, the patient recalled all the words indicating a standard CDT. She is normal for her age with no detrimental cognitive impairment. This patient reports sleep disturbances, and anxiety that she can now control without medication.

Plan of Care

For the patient assessed, her priority needs include risk for accidents and decreased appetite. Her accidents are due to her condition which requires that she have a fulltime caregiver living by her side. Her decreased appetite is due to her age. Her decreased appetite can result in malnutrition. Her nutrition should be monitored closely. Considering she spends most of her time alone, her family member has been instructed to encourage her to eat regularly. If these priorities need and intervention are put in place, it could better her health and prevent hospitalization.

References

Graf, C. (2008). The Lawton instrumental activities of daily living scale. AJN The American Journal of Nursing, 108(4), 52-62.

Hudson, P. L., Trauer, T., Graham, S., Grande, G., Ewing, G., Payne, S., & Thomas, K. (2010). A systematic review of instruments related to family caregivers of palliative care patients. Palliative medicine, 24(7), 656-668.

Sergi, G., De Rui, M., Sarti, S., & Manzato, E. (n.d.). Polypharmacy in the elderly. Drugs & aging, 28(7), 509-518.

Suominen, M. H., Sandelin, E., Soini, H., & Pitkala, K. H. (2009). How well do nurses recognize malnutrition in elderly patients? European journal of clinical nutrition, 63(2), 292.