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WALDEN NR 305 - Health Assessment

Course: Nr 305-
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2021 NR-305 Health Assessment -Week 2 Discussion General Survey/Skin/Nutrition The areas that I would be observing immediately upon arrival at their home would be Millie’s level of consciousness since she was staring blankly out of the window. Look at her skin color on her bottom since she has been sitting in her wheelchair and she has problems with incontinence, also look at her overall behavior. Like her facial expressions, mood, speech, dress and personal hygiene. I would check her vital signs like temperature, weight, pulse, respirations and blood pressure. With a history of hypertension and CVA vital signs are important. I would also do the same for Fred her husband. The concerns I have related to Millie’s skin and nutritional status can affect her negatively. It is important to assess and address any skin lesions if any. Since she has intermittent bowel and bladder incontinence and at times is forgetful regarding her incontinence, she needs to be monitored closely. Checking her weight for weight loss and calculating her BMI will help with any evidence of malnutrition. Checking with Fred to see what he is making for lunch and make sure it is nutritional for them both. Since she is forgetful at night, I would teach her to set an alarm to make herself use the restroom at night. Teach her proper ways to clean herself. For example, wiping front to back. Fecal incontinence is associated with a higher poor nutritional status and is associated with a higher rate of injury (Junkin & Selekof, 2007). Check the skin on her perineal area and buttock for any skin breakdown and teach her pelvic floor exercises to strengthen pelvic floor. I will also make sure Millie is eating a well-balanced diet. If Millie had a sore on her bottom, we would be concerned if the sore would heal properly. “Older adults have increased risk of under nutrition or over nutrition” (Jarvis, 2016, pg. 182). Also teaching Millie aerobic type of exercises which will help cardiac health and resistance training to treat weakened muscles. For Fred, we would make sure he is getting enough fluid and taking antibiotic as directed. Healthy eating patterns would also be a concern for Fred. Some teaching strategies to educate Millie and Fred on their new medications is key. For the Novolin R per sliding scale, we will make sure that Millie knows how to take and record blood sugars daily and how to calculate totals so she will know how much medication to use. Other strategies to teach her are signs and symptoms of hypoglycemia and what are the risk if an episode is untreated. For the Zithromax for Fred, we would teach him that Zithromax is an antibiotic to treat his PNA and he will need to take it as directed and finish the dosage. Stress the importance that an infection may not clear up if medication is stopped too soon. Will teach him to take medication with food since food may enhance tolerability. Using SBAR for Millie, I would discuss that she is an 83-year-old woman, taking care of her 87-year-old husband. She has a history of HTN, DMII, CVA with left-sided weakness, alert and oriented (but forgetful at night), decrease level of conscience, intermittent incontinence of bowel and bladder, needs assistance with ADL’s, and uses wheelchair intermittently. My assessment on Millie would be possible risk for skin breakdown or infection, and loss of weight due to age and meal preps by husband. Myrecommendations for Millie would be my concerns that she may develop bed sores and she may be losing too much weight. Possibly have live-in Home Health Aid or have one come daily to assist with ADL’s to properly clean/bathe her and assist her to the bathroom. Have a dietician contact them with proper meal planning or someone to help with cooking. Last resort if these do not help would be suggesting a nursing home. Lastly for Fred the proper SBAR I would discuss with doctor would be that he is an 87-year-old man busy preparing lunch, but he is just recovering from a 9-day hospital stay for Pneumonia, dehydration, and failure to thrive. My assessment on Fred would be that he may be overwhelmed with preparing meals for himself and his wife. Continued failure to thrive and dehydration. My recommendations would be the same as Millie, and have a live-in Home Health Aid to help prepare meals or go grocery shopping for them. I would also inquire about meal preparation facilities. Have a dietician contact them with proper meal planning. References Jarvis, C. (2016). Physical examination & health assessment. (7th ed.) Philadelphia, PA: Saunders. p.182 Junkin, J., Selekof, J.L. (2007). Prevalence of incontinence and associated skin injury in the acute care inpatient. Journal of Wound, Ostomy & Continence Nursing, 34(3),


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