Nursing Plan of Care for an Older Adult

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Table of Contents

Identification and Description of the Client
The Clients Strengths
The Client’s Weaknesses
Overall impression of Client’s Needs
Summary and Interpretation of Assessment
Nursing Care Plan for SM
High Blood Pressure or Hypertension Care Plan
Diabetes Care Plan
References

The aged population forms a majority of the proportion that needs special healthcare, this due to the fact that they require unique and diverse needs that comes only with old age. Boult et al. (1994) affirm that most of the aged suffer from chronic conditions and illnesses that require special and personal attention due to the psychological changes they undergo as they age (p. 28). This paper provides an assessment of SM; an elderly patient, and provides a care plan that identifies two of her nursing diagnosis needs.

Identification and Description of the Client

The client is known as SM; she is seventy two years old and was born on the twenty-eighth of February 1940. SM is a divorced female and a mother of two daughters and two sons, eight grandchildren, and three great grandchildren. SM worked for forty years as a sterilization technician and supervisor in the operating room at Our Lady of Bellefonte Hospital before retiring.

The Clients Strengths

She is active around the house and does her own laundry, cooks her own meals, and does much of her own housework.
She is able to complete bathing, dressing, transferring, feeding, and continence on her own without any assistance.
She is able to use the telephone, do shopping, use transportation, and take responsibility for her own medication without any assistance.
She does not have any cognitive impairment, and she is mentally alert and oriented
She is able to drive the car, manage her own financial resources like writing checks without any assistance.

The Client’s Weaknesses

She is poor in health and has a medical history of heart disease, diabetes, hypertension, and hypothyroidism.
She has difficulty with seeing in distances which makes her use spectacles in both distance and in reading.
She has hearing problems and is HOH in both ears but marked worse in the right ear.
She has dental problems and most of her teeth are decayed needing extraction.
She is diabetic but continues to eat sweets for breakfast and does not monitor her diet as a whole; this has resulted into her being obese.
She is ignorant on diet issues, since she believes that her thoughts and choices concerning what she eats will not make a difference in her blood sugar because the problem is genetic.
She is at risk of falls because she is somewhat unsteady when turning around.
She has poor strength and stamina due to her inability to stand from a seated position suggesting she needs simple exercises or physical assessment.
She has difficulty with the serial number seven.

Overall impression of Client’s Needs

SM has a number of chronic complications which require special attention. First of all, she has a medical history of heart disease, hypertension, hypothyroidism, and diabetes. In addition she is obese, has a pink, warm, and dry skin, and has evidence of varicose veins. SM also has dental problems with most of her teeth decayed requiring extraction.

These conditions place her in a position of need requiring special attention from both family members and from the medical field. First of all, SM needs education on the importance of watching her diet and weight so that she can regulate what she eats and gets involved in regular exercise. Dieting will help reduce her weight and eliminate unwanted sugars from her body and the exercises will keep her fit, alert and improve her stamina. She also needs to be educated on the importance of hearing aids to help boost her hearing abilities. In addition she needs financial support to pay the oral surgeons bill to have her decayed teeth extracted. Above all SM needs education concerning her thoughts on her health life, since her presumptions are not necessarily true.

Summary and Interpretation of Assessment

From the assessment of the client, her lungs were clear to auscultation, her temperature was ninety-eight point three, her blood pressure was 128/84 and her pulse rate was seventy. SM’s nutritional screen was 6+; she weighs two hundred and thirty five pounds, and is five feet six inches tall. Her functional performance test scored four, her gait speed was greater than five point six seconds, and her pace was slower totaling to nine point four seconds. SM’s Katz score was six, her mini mental status scored twenty five and her brief pain inventory results revealed that she was not in any pain at the time of the assessment. The client’s instrumental activities of daily living scale shows that she can carry out a number of activities like preparing her own meals, doing household chores among other minor activities without any assistance.

The assessment also reveals that the client is on medication, and he medication list includes; Coumadin which she takes as a blood thinner once every day and Lasix which she takes as a fluid pill twice every day. She also takes Clonidine for her blood pressure, Pravastatin for her cholesterol levels, Metoprolol for blood pressure and Gyburide which she takes as a sugar pill. In addition to these, she also takes Synthroid for her thyroid, Diovan for her blood pressure, and Aspirin which she is not sure why she takes as her doctor told her to take it.

Nursing Care Plan for SM

This nursing care plan simply outlines the nursing care to be provided to the client. It includes a set of actions that the caring nurse will implement to support or resolve the nursing diagnoses that have been identified by the nursing assessment. The North American Nursing Diagnosis Association (2011) requires that the nursing plan contain a nursing diagnosis which provides the criteria for selecting the best nursing intervention. In this respect this paper develops two care plans for two of SM’s diagnostic needs that are, high blood pressure and diabetes.

High Blood Pressure or Hypertension Care Plan

Nursing Diagnosis: decreased cardiac output
Risk Diagnosis: the patient has a risk of falling and a risk of shock
Health promotion diagnosis: patient is ready and willing to take medication

Date	Subjective information	Objective information	Patient Outcomes	Nursing Interventions	Evaluation
(date of Assessment)	Client is obese, her skin is pink,	Temp 98.3 BP128/84 PR 70 Katz score 6 Lungs clear Bowel sounds active	Normal blood pressure levels of 120/40, normal body temperature, normal skin color, normal breathing	Monitoring the blood pressure. Observing skin color, moisture, temperature and the capillarity filling time. Observing general edema (Earl et al., 2002, p. 357). Maintaining fluid and drugs. Ambulation according to ability	Maintain the required blood pressure

Diabetes Care Plan

Nursing diagnosis: imbalanced nutrition, the body takes more than the required Risk diagnosis: risk of injury: and activity intolerance
Health promotion diagnosis: patient continues to take much sugary food citing the diabetes is genetic.

Date	Subjective information	Objective information	Patient outcomes	Nursing interventions	Evaluation
Date of assessment	The patient is obese, experiences increased urination, has poor vision and thus uses glasses,	Nutritional screen 6+, weight 235 pounds, height 5ft. 6in.	Nutrition balance, proper eating habits, proper diet control	Advise client on the importance of dieting, weight loss, and exercise. Advise patient to reduce intake of sugars.	Maintain an ideal body weight

In conclusion SM requires immediate medical attention, and if the plan described above is well adhered to, her progress monitored daily, progress will be observed.

References

Boult, C., Kane, R. L., Louis, T. A., Boult, L., & McCaffrey, D. (1994). Chronic conditions that lead to functional limitation in the elderly. Journal of Gerontology, 49(1), 28- 36.

Earl, S. F., Giles, W. H., Dietz, W. H. Robert, G. H., & Houza, T. M. (2002). Prevalence of the metabolic syndrome among US adults. JAMA, 287(3), 356-359.

Mitty, E., & Mezey, M. (1999). Integrating advanced practice nurses in home care: Recommendations for a teaching home care program. Nursing and Healthcare Perspectives, 19 (6), 264-270.

North American Nursing Diagnosis Association. (2011). Diagnosis development. Web.

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