NR 442 iHuman patient Shamjibhal Bhai
Prework
A 75 year-old male has come to the clinic for a comprehensive health assessment
1. What are your
... [Show More] primary concerns for this patient and what assessments and interventions would be associated with your concerns? Why?
One of the main concerns here will be to assess physical function as well as vision check, and hearing check to ensure the patient is able to accomplish activities of daily living, if not then we can redirect him to the right resources. Another assessment that’s important would be cognitive assessment because the elderly population are prone to be in a confused state in case of an infection. We also need to make sure he is up to date in his immunization especially the influenza and pneumonia vaccines.
Patient safety at home with medication, nutrition,
Intervention: proper diet, interview pt to find out more info.
Pain with urination?
2. What additional assessment or tests would be done for an elderly person.?
Additional assessment that can be done are skin check, neuro check, medication review, urinalysis, blood work, nutrition or diet assessment, social activities, psychological and mental assessment, as well as economic and environmental status.
Nurses notes
Shamjibhai a 75 year old male came to the clinic for the first time today for a comprehensive health assessment. He and his wife recently moved across the country to live with their daughter and her children. He has not established an HCP yet. He is retired but is looking to volunteer at a local shelter and it is required he has a health assessment prior to starting.
Height/weight: 5 6’’ 135 lbs
Temp: 98.4 F
Pulse: 68
RR: 22
SpO2: 98%
BP: 124/80
Mr. Shamjibhai has a family history of diabetes. He lives with his wife and daughter and have 4 children in the house. Review of system is as follow:
Skin: warm and dry, normal skin turgor for given age, solar lentigo (liver spots) noted on hands and forearms, acrochordons (skin tags) noted to right axilla. Normal appearing nails without ridging, pitting or peeling. Capillary refill is less than three seconds.
HEENT: conjunctivae is pink, no discharge. Sclerae is anicteric, no edema, redness, tenderness or lesions noted in the orbital area. Ectropion eyelids to lower part is noted. Normal appearing external structures, no deformities or edema, no discharge noted. Normal appearing external auditory canals, tympanic membrane translucent, pinkish gray in color, no scarring, discharge or purulence noted. Normal exam on neck, thyroid moves with swallowing.
Chest wall and lungs: the chest is symmetrical, and the anterior-posterior diameter is normal, the excursion with respiration is symmetrical and there are no abnormal retractions or use of accessory muscles, no distension, scars, masses or rashes. Lungs are clear times all lobes.
Cardiac: heart rate of 68, regular rhythm and 2+
Abdomen is flat and symmetric with no scars, deformities, striae or lesions, no pain, tenderness, masses or pulsations, there is no guarding or rebound tenderness, no hepatosplenomegaly. Liver span normal, the spleen is not palpable.
Musculoskeletal: normal, equal bilaterally for given age.
GU: normal external genitalia no masses or tenderness, no urethral discharge.
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