Subjective Data
J.P. is a 75-year-old retired factory worker being seen in the home setting for a yearly health assessment provided by his insurance company.
Subjective Data
No complaints at this time
Enrolled in Silver Sneakers
Eats out much of the time
Widowed
Has one daughter who lives in another state
Retired automotive parts factory worker
Drives to and from activities
Objective Data
Vital signs: T 37 P 80 R 18 BP 140/68
Weight: 200
HT: 5 feet, 6 inches
Questions
How should the nurse proceed with the interview portion of the assessment?
What are the components necessary to complete the interview?
Develop a problem list for subjective findings.
Develop a problem list for objective findings.
What teaching should the nurse consider from the problems list?
What interventions might be included in the plan of care for this patient?
Sample Solution
J.P.'s Home Health Assessment: Interview and Care Plan
Interview Approach:
The nurse should conduct a comprehensive interview using open-ended questions to explore J.P.'s health and well-being in a holistic manner. Here are some key areas to focus on:
- Medical history: Explore past diagnoses, current medications, surgeries, and immunizations.
- Functional status: Assess J.P.'s ability to perform daily activities like bathing, dressing, cooking, and shopping.
- Mental health: Screen for mood changes, depression, anxiety, and cognitive decline.
- Nutrition and diet: Investigate J.P.'s usual dietary patterns, including frequency of eating out and food choices.
- Social support: Evaluate J.P.'s social network and potential for isolation or loneliness.
Full Answer Section
- Safety and environment: Assess home safety hazards, access to transportation, and support for managing medications.
Interview Components:
- Current health concerns: Ask J.P. about any specific health concerns or changes he has noticed.
- Lifestyle habits: Explore J.P.'s sleep patterns, physical activity level, alcohol consumption, and smoking history.
- Advance directives: Determine if J.P. has completed advance directives like a living will or medical power of attorney.
- Goals and priorities: Discuss J.P.'s goals for maintaining his health and independence.
Problem List:
Subjective:
- Potential nutritional risk due to frequent eating out.
- Loneliness or social isolation due to being widowed and daughter living far away.
- Potential risk for cognitive decline due to age and potential health conditions.
Objective:
- Hypertension (BP 140/68).
- Overweight (BMI 28.6).
Teaching Considerations:
- Healthy eating habits and portion control.
- Importance of social interaction and building local support networks.
- Early detection and management of cognitive decline.
- Medication adherence and potential side effects.
- Lifestyle modifications for controlling blood pressure and weight.
Interventions:
- Refer J.P. to a nutritionist for dietary counseling and meal planning.
- Encourage joining local senior centers or community groups for social interaction.
- Screen for cognitive decline using standardized tools and refer for further evaluation if needed.
- Provide education on proper medication use and potential side effects.
- Recommend weight management strategies like healthy eating and regular physical activity.
- Refer J.P. to his primary care physician for follow-up and management of identified health concerns.
Additional Notes:
- Encourage J.P. to continue participating in Silver Sneakers for maintaining physical activity.
- Monitor J.P.'s functional status and provide appropriate resources if needed to ensure safety and independence at home.
- Collaborate with J.P.'s daughter to provide additional support and resources.
Remember, this is a general plan based on the limited information provided. A thorough assessment and ongoing monitoring are crucial for tailoring the care plan to J.P.'s specific needs and preferences.