Subjective Data

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.

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.