Assessment: Data Collection Sheet

Assessment: Data Collection Sheet
Assessment: Data Collection Sheet
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NURS 420: Gero Assessment
Client Initials: KV M/F: Male Age: 84 Student: Kris Brokke Date: 9/15/17
NOTE: short responses and/or bullets are sufficient for this project; word process right in the table cells and let the paper expand as needed.
Introduction Questions:
1. Would you rate your current state of health as excellent, good, fair, or poor? “I would rate my current health status as good, I do not have any complaints at this time.”
2. Why did you select this rating? “I feel normal, no pains right now. I just take a few medications for my health.”
3. What does it mean to be healthy as you age? “It is important to me at my age to have good health. It means I am free of disease or infections…that sort of stuff.”
Criteria Client Findings
1. Current health problems and their functional impact. Health Problems
1. Asthma
2. High Cholesterol
3. Benign Prostatic Hyperplasia (BPH)
Functional Impact
à Waking up during the nighttime occasionally with breathing issues.
à Blood pressures, at times, have been elevated.
à Waking up during the nighttime, very frequently, with bladder issues (polyuria).
2. Current medications, their indications and effects. Medications Indication Nurses Only: (precautions)
-Adverse Effects, Target goal, Lab Monitoring
1. Symbicort
2. Zocor
3.Tylenol
4. Flomax
5. Preservision
6. Bayer, low dose aspirin
1. Symbicort is used to prevent bronchospasms for people who suffer from asthma or chronic obstructive pulmonary disease.
2. Zocor is used to lower cholesterol and triglycerides in the blood.
3. Tylenol is a pain and fever reducer.
4. Flomax is used to improve urination in men with BPH.
5. Preservision is a daily multivitamin formulated to promote eye health.
6. Bayer, low dose aspirin is used to treat pain, and reduce fever or inflammation. It is sometimes used to treat or prevent heart attacks, strokes, and chest pain (angina).
(Davis Drug Guide, 2017)
Symbicort: Precautions: adrenal suppression related, asthma related, bone density, bronchospasm, hypersensitivity reactions, lower respiratory infections, oral candidiasis, serious effects/fatalities, vasculitis; cardiovascular disease such as elevation of blood pressure and heart rate causing CNS excitation, flattening of the T wave, prolonged QTc interval, ST segment depression; COPD – do not use with acute episodes; Diabetes – beta agonists may increase serum glucose and aggravate preexisting diabetes mellitus and ketoacidosis; hepatic impairment – may lead to accumulation of drug itself; hypokalemia – beta 2 agonists such as formoterol decrease serum potassium; ocular disease – may cause increase in intraocular pressure in patients with glaucoma or cataracts; seizure disorders – beta agonists may exacerbate as they cause stimulate CNS activity; thyroid disease – steroid clearance changes based on hyper- or hypothyroidism.
Budesonide may result in serious side effects or lead to death. Formoterol can cause affect heart rhythm abnormalities. EX: QT-interval prolongation, which can lead to Torsades de Pointes, which can trigger ventricular fibrillation. Budesonide can lead to immune suppression as it is a steroid. If stopped too quickly, it may lead to Addisonian Crisis’-like symptoms (extreme fatigue, weight loss).
Adverse effects: CNS – headache; Respiratory – nasopharyngitis or URI, pharyngolaryngeal pain; Gastrointestinal – abdominal distress, oral candidiasis, vomiting; Infection – influenza
Target Goal – We want to see the Symbicort exerted full effect of its steroid (budesonide) and beta 2 agonist (formoterol) components. The long acting beta 2 agonist will lead to longer relief from bronchospasm. The corticosteroid will prevent the bronchioles from becoming irritated and inflamed, furthermore, allowing the patient to much more easily breathe from day to day. The mechanism of action of formoterol is to bind agonistically bind the beta 2 receptor of the bronchioles to promote bronchodilation. The mechanism of action of budesonide is to depress the migration of polymorphonuclear leukocytes, fibroblasts; reverses capillary permeability and lysosomal stabilization at the cellular level to prevent or control inflammation. Has potent glucocorticoid activity and weak mineralocorticoid activity.
Labs: Check CBC, CMP
Zocor Precautions: Diabetes – increases serum glucose and HbA1c. Hepatotoxicity – get liver function tests at baseline to assess appropriately. Immune mediated necrotizing myopathy – may persists even after the discontinuation of statin therapy. Myopathy/rhabdomyolysis – this is more prevalent when using other lipid lowering therapies, age> 65, female gender, uncontrolled hypothyroidism, and renal dysfunction, colchicine use. Avoid in patients who consume large amount of alcohol. Avoid high dosage in Chinese patients if concurrently taking Niacin >1g/day.
Adverse Effects: Cardiovascular – atrial fibrillation, edema; CNS – headache, vertigo; Dermatologic – eczema; Gastrointestinal – abdominal pain, constipation, gastritis, nausea; Genitourinary – cystitis; Hepatic – increased LFTs (3x UL); Neuromuscular and Skeletal – increased CPK, myalgia; Respiratory – URIs, bronchitis
Target goal of Zocor, a statin medication, is to lower LDL, cholesterol, triglycerides. The medication can also raise HDLs. Target goal of HDL is 60 or more men. LDL is less than 150 is a healthy male.
Labs: Check LFTs, CPK and myoglobin, Lipid profile
Tylenol Precautions: Hepatotoxicity- do not exceed >4g/day; hypersensitivity/anaphylactic reaction – discontinue if signs of these reactions occur; skin reactions – beware of stevens Johnson, toxic epidermal necrolysis, ;ethanol use – avoid taking medication during acute or chronic alcohol consumption;G6PD deficiency; hepatic impairment ;hypovolemia – not safe in the severely dehydrated patient; malnutrition ;renal impairment
Adverse Effects: Dermatologic – skin rash; Endocrine and Metabolic – decreased sodium bicarbonate, decreased serum calcium, decreased serum sodium, hyperchloremia, hyperuricemia, increased serum glucose; Genitourinary – nephrotoxicity in chronic overdose; Hematologic and oncologic – anemia, leukopenia, neutropenia, pancytopenia; Hepatic – Increased Alk Phosphatase, increased Bilirubin; hypersensitivity – hypersensitivity reaction; Renal – hyperammonemia, renal disease
Target goal – Medication is working to reduce somatic pain and fever. inhibit the synthesis of prostaglandins in the central nervous system and work peripherally to block pain impulse generation; produces antipyresis from inhibition of hypothalamic heat-regulating center
Labs: Check LFTs if patient has precautions
Flomax Precautions: Angina – discontinue if symptoms occur or worsen; floppy iris syndrome – may occur intraoperatively during ophthalmic surgery potentially causing complications. Patient should advise medical professional that they are on Flomax prior to surgery. Orthostatic hypotension: avoid if using other anti-hypertensives especially vasodilators like PDE-5 inhibitors (sildenafil, tadalifil, vardenafil. Advised about performing hazardous tasks such as driving and operating heavy machinery; priapism – rarely occurs; sulfonamide allergy – avoid if ever had a reaction to Sulfa; heart failure – may exacerbate underlying myocardial dysfunction; prostate cancer – rule out prostate carcinoma before initiation and then screen at regular intervals.
Adverse Effects: Cardiovascular – orthostatic hypotension; CNS – headache, dizziness, drowsiness, insomnia, vertigo; Genitourinary – ejaculation failure; Infection; Respiratory – rhinitis, pharyngitis, cough, sinusitis; Endocrine and metabolic – loss of libido; Gastrointestinal – diarrhea, nausea; Neuromuscular and skeletal – weakness, back pain; ophthalmic – blurred vision
Target Goal: Medication is used to reduce nocturia and intermittent stream. Works as an alpha 1 antagonist in the prostate leading to relaxation of smooth muscle in the bladder neck.
Labs: N/A
Preservision Precautions: Iron toxicity, hepatic impairment, renal impairment, ethanol
Adverse Effects: abdominal pain, vomiting, constipation, diarrhea
Target Goal: Patient may take this on a voluntary basis
Labs: N/A unless Iron toxicity is suspected
Bayer low dose aspirin precautions: Salicylate toxicity if sensitive to tartrazine dyes, nasal polyps, and asthma; tinnitus; upper GI bleeding; bleeding disorders, dehydration, ethanol use, GI disease, hepatic impairment, renal impairment; do NOT use with alteplase in treatment of ischemic stroke within if given within 24 hours; do NOT use with other COX-2 inhibitors/NSAIDs
Adverse Effects: Cardiovascular – Cardiac arrhythmia, edema, hypotension, tachycardia
Central nervous system – Agitation, cerebral edema, coma, confusion, dizziness, fatigue, headache, hyperthermia, insomnia, lethargy, nervousness, Reye’s syndrome
Dermatologic – Skin rash, urticaria
Endocrine & metabolic – Acidosis, dehydration, hyperglycemia, hyperkalemia, hypernatremia (buffered forms), hypoglycemia (children)
Gastrointestinal – Gastrointestinal ulcer (6% to 31%), duodenal ulcer, dyspepsia, epigastric distress, gastritis, gastrointestinal erosion, heartburn, nausea, stomach pain, vomiting
Genitourinary – Postpartum hemorrhage, prolonged gestation, prolonged labor, proteinuria, stillborn infant
Hematologic & oncologic – Anemia, blood coagulation disorder, disseminated intravascular coagulation, hemolytic anemia, hemorrhage, iron deficiency anemia, prolonged prothrombin time, thrombocytopenia
Hepatic – Hepatitis (reversible), hepatotoxicity, increased serum transaminases
Hypersensitivity – Anaphylaxis, angioedema
Neuromuscular & skeletal – Acetabular bone destruction, rhabdomyolysis, weakness
Otic – Hearing loss, tinnitus
Renal – Increased blood urea nitrogen, increased serum creatinine, interstitial nephritis, renal failure (including cases caused by rhabdomyolysis), renal insufficiency, renal papillary necrosis
Respiratory – Asthma, bronchospasm, dyspnea, hyperventilation, laryngeal edema, noncardiogenic pulmonary edema, respiratory alkalosis, tachypnea
Target Goal: used as an analgesic, antipyretic, antiplatelet, and anti-inflammatory. Irreversibly inhibits COX-1 and COX-2 enzymes leading to decreased prostaglandin formation.
Labs: Check CBC if UGIB is suspected.
(Davis Drug Guide, 2017)
3. Previous surgeries and/or health problems
Bowel blockage back in 2010, surgery to remove blockage completed the next day. Vertical scar noted on abdomen. Shingles flare in 2013, successfully treated with Acyclovir. History of syncope, last instance was back in 2014, when he passed out in a local pizza place. No injuries or residual affects noted. Does not receive medication for this condition, but blood pressure medications were adjusted to help reduce the occurrence.
4. Recent and impending life changes (deaths, moves, stressors, hospitalizations) Stressors concerning his son, Troy and the family farm during the harvest season of soy beans. States that he thinks about it all day and it bothers him a lot during the day. He has never taken an anti-anxiety/depression medication in the past.
5. What activities engaged in to maintain or improve health? How does this affect their personal and social functionality? He is very active, states, “I love walking at the mall, going to the YMCA to walk the track and participating in all the activities that I can. I am not one for sitting around.” By being active, it allows him to maintain his independence and have a healthy social life. States, “By being able to keep my independence, I feel like I am much younger. I really hate relying on others for help, even though I know I may need help in the future, I really like where I am now.” He also went on to talk about how having a social life makes it easier on him emotionally, because “a lot of my friends have gone and passed away, but I enjoy being close to those around me and going out for coffee every day.” Having a healthy social life is very important to him.
6. Current and future living environment and its appropriateness to ADL function and long-term prognosis? How does it contribute to their health? Is it appropriate? Any safety concerns?
Lives at home with his significant other. At this time, he would like to remain at home, but knows that if his needs become too great for him to handle he may need to move to an assisted living facility. He can complete activities of daily living (ADL’s) appropriately. Long-term prognosis is good in his own words. He does not have any artificial limbs, and rarely must climb down the stairs. He does not have a history of falls in his home. Episodes of syncope have happened when out of house. This is still a major concern for him, as well as myself. When assessed on how safe he feels, states, “I have good neighbors that are always willing to help me out.” Resident seems to have anxiety as a result of this uncertainty, which raises his blood pressure and heart rate. States, “When I start to worry about these type of things, I feel as though I could pass out. It is really quite odd.” Resident’s memory assessed, I did notice issues when assessing home, resident’s health history and past events. At times, recalling events would be very clear and then he would become confused and change the entire story or event. He also states, “I cannot seem to remember faces or names very easily anymore.” Resident stated that his family has a history of dementia, but he wasn’t sure if he had dementia.
7. Family situation and availability. Provide details. Both of his son’s live on their family farm located in Campbell, Minnesota. His daughter, lives minutes away in Fergus Falls, Minnesota. Sister and brother-in law, both live at a nursing home a few blocks away from where he currently lives.
8. Current caregiver network including its deficiencies and potential for improvement. Caregiver network from Lake Region Hospital in Fergus Falls, Minnesota. Deficiencies: States, “I really cannot complain, I feel as though I am very well taken care of. I can’t see anywhere they could improve.”
9. Objective measure of cognitive status, forgetfulness, etc. Explain. I have known him all of my life, and have seen his memory slowly decline. When assessing his memory, I was actually alarmed at how much he had declined. He states, “I know I am very forgetful at times, I will always know your name, but I have lots of trouble remembering other people’s.” He is alert and oriented x4, with no complaints of headaches, pains in his neck/back region. Pupils equal, and reactive to light. When using the General Practitioner Assessment of Cognition (GPCOG) tool, he scored a 7, which means he is moderately impaired cognitively (Alzheimer’s Association, 2017).
10. Objective assessment of mobility and balance. Explain. Throughout knowing him, he has been known to be very active in the community and in his yard work. During my assessment, which was over 3-4 days of watching him complete ADL’s, I really do not have any concerns regarding mobility, but as far as balance I fear that he may fall and break a hip or worse. He also has a history of passing out, which could potentially be fatal if he falls down the stairs and hits his head. His ROM is normal in all extremities and does not complain of pain. He is able to reach cupboards, drive his car and walk the mall or YMCA with ease.
11. Rehabilitative status, prognosis, how long they can be expected to stay in current living situation? Assistance or home modifications needed? With his current living situation and comorbidities, he can be expected to stay in his current living situation for at least another 5-6 years. He is a very active elderly man, with a great support system to make sure he is staying healthy. If complications were to arise, he states, “I would like to go to the nursing home a few blocks away and live with my sister.” Home modifications that may be needed are to install better lighting in hallways and to install better, more tightly fastened hand rails on stair case. It would also be important for him to have a button to call for help in case he fell and was not able to call for help.
12. Current emotional/mental health and substance use/abuse? Explain. He has never been diagnosed with any psychiatric disorder. He has never taken an antipsychotic/depression medication. When assessed on thoughts of suicide, he had stated that he had never once had suicidal ideation. “The saddest I have ever been is when my first wife died, it was tough on me emotionally, but I was able to get through it because of strong family and friend relationships.” He also stated that he had never abused alcohol or drugs, but found himself becoming addicted to coffee (caffeine). According to Webster.edu, “The final stage of Erikson’s (1982) theory is later adulthood (age 60 years and older). The crisis represented by this last life stage is integrity versus despair. Erikson (1982) proposes that this stage begins when the individual experiences a sense of mortality. This may be in response to retirement, the death of a spouse or close friends, or may simply result from changing social roles. No matter what the cause, this sense of mortality precipitates the final life crisis. The final life crisis manifests itself as a review of the individual1s life-career” (Webster, 2010). With this information, I would conclude that he is in the despair because he reflects on his life, stating, “I remember when I was your age, I used to be so optimistic with my life. Now I am an old man.”
13. Religious affiliation & significance. Explain. He is a follower of Christ, stating that he is a Baptist and attends church regularly because it fills him with joy and hope for the rest of his life.
14. Nutritional status, Ht/Wt/BMI, who grocery shops, what do they have in the fridge/cupboards, who cooks, describe typical meals? Community resources? Explain. Nutritional status: He eats 3-4 small meals a day, mainly consisting of a type of carbohydrate and a meat. One day he would eat toast and coffee for breakfast, left overs lunch and a personal pan pizza for supper, the next day he would go out to eat for every meal. He really enjoys McDonald’s coffee as well as their breakfast’s. He is 5’ 9” tall, and weighs 208 pounds. The U.S. National Institute of Health (2017) predicts his BMI to be 30.7 which means he is obese. He states, “My girlfriend normally shops for me, I tell her what to get and she drives to Walmart to get it.” His cupboards and fridge consist of a variety of different foods including: Cereal, granola bars, chips, white milk, apples, coffee, bananas, potatoes, chicken and TV dinners. He does not have any community resources set-up for him now, stating, “I don’t see the need right now.”
15. Preventive health, immunizations, screenings, and health promotion activities.(include dates) Immunizations Screenings Health Promotion
Prevnar 13- Complete on 9/28/15.
Prevnar 23- Complete on 11/15/16.
Tdap- Complete on 4/28/17.
Zoster-N/A
Flu- Complete on 10/13/17.
Other
2-Step Mantoux started on 3/13/17 and completed on 3/31/17 (results negative both times).
Depression- N/A
Colonoscopy-Completed in 2015, with no new findings.
Mammogram- N/A
AAA screen- N/A
Lung Cancer screen- N/A
Diabetes-HTN- Completed in January of 2017 by their Primary care provider (PCP).
Hearing/Vision- Completed in January of 2017.
Hepatitis C- N/A
Alcohol- No alcohol consumption
Drug use- No drug use
Smoking- Does not smoke
Dentist- See’s his dentist every 6 months for routine cleaning.
Eye Exam- Has eye glasses adjusted once a year, “typically in February.”
Advanced Directive (Explain)
Advanced directives in place, his son, Troy is his Power of Attorney (POA). He would not like to be resuscitated (DNR), if the circumstance were to arise. He is willing to take and receive care regarding infection, surgery and antibiotic use. Physician’s Orders for Life-Sustaining Treatment (POLST) not in place at this time.
16. Services required and received. (home care, Soc.Security, pensions, health insurance, community programs). Explain.
The services required now are quite slim, he does not have a home health agency involved in his care. He does have social security checks each month which help him to continue to live in his home. He has health insurance through Medicare, he was unable to give me specifics on what plan he currently is on. He does not have a pension because he was a farmer. Lastly, he does not accept aid from any community programs at this moment.
Concluding Questions:
1. What suggestions do you have for others about health in aging? “Stay active, wash your hands, and be safe in the shower.”
2. What suggestions do you have for nurses/health care providers/NH administrators about health in the elderly? “I cannot think of very much, but one thing I really enjoy is when my providers are patient with me and listen to my every need attentively.”
Part 3: Functional Assessments (5 points)
Select One: SPICES, Lawton, or Katz
For this assignment, I will be using the Lawton Functional Assessment tool.
Try This Tool Description of Tool* Pt. Score & Interpretation Follow-up intervention needed?
1. Lawton
*include brief description, sample questions, scoring range, interpretation of score, etc.
Part 4: 5 “TRY THIS” Assessments (25 points)
*include brief description, sample questions, scoring range, and interpretation of range of scores.
Note: Borderline scores may still require f/u. (use critical thinking skills and clinical reasoning)
Try This Tool Description of Tool* Pt. Score/ Interpretation F/u Intervention needed? (Y/N)
1. Mental Health
(choose 1: Depression, Dementia, or Confusion)
2. Fall Risk
3. Pain
4.
5.
Part 5: Prioritized Problem List or Functional Deficit (10 points)
(One problem/deficit must be Health Promotion)
Problem/Deficit Evidence
1.
2.
3.
Etc.
Part 6: 3 SMART Goals and Interventions (15 points)
(One SMART goal and Intervention must be focused on Health Promotion)
Problem/Deficit SMART goal Significant Evidence-Based Intervention
1. Shortness of Breath Secondary to Asthma
Gauge progress by measuring the amount of episodes of shortness of breath per day and amount of night time awakenings throughout the next 6 weeks. May use albuterol for breakthrough symptoms that Symbicort does not cover. If symptoms worsen, consider adding a long acting muscarinic antagonist.
2. Hyperlipidemia
Gauge progress by continuing lipid lowering regimens while monitoring LDL, HDL, cholesterol, triglycerides throughout the next 2 months. Initiate a low carbohydrate, low fat diet with daily cardiopulmonary exercise along with Zocor and low dose aspirin to prevent any myocardial ischemic events.
3. Benign Prostatic Hyperplasia
Gauge progress by measuring the regularity of intermittent streams throughout the next 6 weeks. If symptoms such as nocturia and intermittent urination continue, consider switching to a 5 alpha reductase inhibitor or combining it with the alpha 1 antagonist.
Part 7: Annotated Bibliography of Evidence-Based Interventions (15 points)
3 articles from peer reviewed journals that support implementation of 3 different EBP interventions: APA reference followed by brief summary including the research study design, findings & application of significant intervention to your client, single spaced, and make full use of the 150 word limit to explain how/why the specific intervention can improve your client’s health.
McCracken, J. L., Veeranki, S. P., & Ameredes, B. T. (July 18, 2017). Diagnosis and Management of Asthma in Adults: A Review. Journal of the American Medical Association, 318(3), 279-290.
Critical Summary (150 words, max)
Asthma is characterized by airway obstruction, hyperresponsiveness and inflammation. This review article takes in to consideration the studies done in randomized, double blind clinical trials to assess the efficacy of each medication. Avoidance of environme Beta agonists are superb for rapid reflief while inhaled corticosteroids (ICS) treat the persistence of asthma symptoms. ICS is used as a once daily medication. Asthma can be controlled with other medications such as long acting bronchodilators such as formeterol. Biologics may also be used if asthma is more severe and persistent. The patient is on Symbicort which is formeterol and budesonide inhaled. According to the review, this is one of the most effective treatment options available.
ARTICLE #2 – cited in APA format
Critical Summary (150 words, max)
ARTICLE #3 – cited in APA format
Assessment: Data Collection Sheet
Critical Summary (150 words, max)
Assessment: Data Collection Sheet
Part 8: Self-Evaluation (10 points)
Write a brief summary in APA format that describes ways this assignment has helped you gain experience and confidence in taking a leadership role in client assessment and applying evidence-based practice interventions into the clinical setting. Estimated length 200-300 words. Single-spaced acceptable to save space.
Assessment: Data Collection Sheet
To submit your final project assignment forms, please save your document with LAST NAME_ assignment title_ date.
Example: Stock_Gero Assessment_March.5.2017
Assessment: Data Collection Sheet
*** For Instructor Use When Grading ***
GAP Grading Rubric
Part Assignment Element Possible Points Points Earned
1 Signed Consent Pass/Fail
2 Data Collection
criteria: thorough, organized, succinct
20
3 Functional Assessment
choose from: SPICES, Lawton, or Katz
criteria: description and interpretation
Assessment: Data Collection Sheet
5
4 TRY THIS screening assessments
includes: mental health, fall risk, pain, plus 2 more priority needs
criteria: include description, interpretation, and address follow-up
25
5 Prioritized Problem List
10
6 Smart Goals (3)
criteria: identified deficit area, patient focused, SMART criteria, intervention clearly stated, one-sentence SMART goal
15
7 Annotated Bib.
includes: 3 articles from peer-reviewed journals, publication within 5 years, 3 different significant interventions, type of article, brief summary, application to client
criteria: 150 words or less, APA reference at top with summary single spaced
15
8 Self –Evaluation
includes: leadership role, client assessment, evidence-based practice
criteria: 200-300 words, APA format
Assessment: Data Collection Sheet
10