You are on page 1of 15

Running head: Assessment

1
Elderly Assessment
Kelsey LeVan
Joseph F. McCloskey School of Nursing at Schuylkill Health
















ASSESMENT 2
Health History
T.V is an 80 year old male who lives alone in a private home in Elysburg, PA. He has
been divorced for 20 years. Regarding educational background, he graduated from Shamokin
Area High School in 1940. After high school, he joined the United States Army and served for 5
years. After the honorable discharge from the military, he assisted his parents in running a local
bar room in Shamokin, PA. After his mother and father passed away, he ran the bar for a few
years, but then gave it to his younger brother. He then worked for 30 years at Weis as a produce
manager from which he retired from. During those he years at Weis, he also did custodial work at
the Mother Cabrini Church in Shamokin, PA and Lourdes Regional High School. He continued
to this custodial work until 2011. Currently, T.Vs considers his health status as relatively
healthy. He has complete knowledge and understanding and manages his health. He fills his
prescription medications at CVS Pharmacy, takes his medications on a routine basis, and visits
his doctor regularly. T.V. has a past history of an acute myocardial infarction in 2009, coronary
artery disease, borderline diabetic type 2, dyslipidemia, presbyobia, and smoked minimally for 1-
2 years. T.V has no known allergies, and has a family history of strokes and myocardial
infarctions. His mother passed away at age 50 related to a stroke.
Physical, Physiological Aging Changes
Upon assessment of the integumentary system, the skin is pink, warm, and dry when
palpated. There are no areas of ecchymosis, or edema noted during examination. There are
wrinkles present but there is loss of hair under the axilla and legs. There are no areas of skin
breakdown. His nails are pink and rounded, but there is a yellow tint on some of his fingernails
which is normal in aging. As aging advances, nail plate thins and nails can become brittle and
more prone to splitting and yellowing (Lewis, Dirksen, Heitkemper, Bucher & Camera, 2010).
ASSESMENT 3
The head is free of any bumps or lesions and the hair is gray and short and
combed to the sides. His hair turned gray due to a decrease in melanin (Lewis, 2011). His neck
is symmetrical with the trachea at midline. The thyroid gland is palpable from behind when
swallowing water. There was no goiter upon palpation.
PERRLA is present bilaterally in both eyes. He has brown eyes and light tan
eyelashes. His sclera is white and does not have any yellow tint, hemorrhages, or any other signs
of abnormalities. Currently, T.V. is wearing his glasses which appear to be clean and functional.
T.V. is wearing the glasses due to common visual changes that associate with aging (Lewis,
2011). As Lewis states, as a person ages, visual acuity is decreased and diminishing of central or
peripheral vision may occur (Lewis, 2011).
The nose is symmetrical in relation to the face. The nasal septum is intact and
there is some hair in each nostril. There is no abnormal drainage from the nosed. Lewis, states
that loss of sebaceous glands and drying of the skin may cause nasal dryness that can lead to
irritation and lesions in the nasal passages. However, T.V. has no such complaints. Sinuses were
palpated on exam and no tenderness or pain was noted.
Upon assessment of the mouth, there are no sores or lesions on the outer lips or on
the gums or mucous membranes. His lips are pink, non-chapped, and contain no cyanosis.
Mouth is pink with all teeth intact. T.V. is able to swallow and stick his tongue out. He does state
that his mouth often gets dry which is related to decrease saliva production that may occur with
aging (Lewis, 2011). His gums and hard and soft palate are pink in color and no clefts are
identified upon examination. T.V. is able to distinguish between sweet and salty tastes and has
no issues with the sense of taste in general. As a person ages, their sense of taste may be altered
ASSESMENT 4
due to decreased amount of taste buds and they may not be able to distinguish between sweet and
salty items (Lewis, 2011). The uvula is intact at the back of the throat and is not deviatated.
Regarding the ears there was no redness, bumps, lesions, or bleeding present. The
ears appear symmetrical with the head and there are no complaints of ear pain. No abnormal
amounts of ear wax were seen. T.V. states that his hearing aids have been working accurately and
he has no issues with them. He does state that times it is difficult to hear and that he may need
things repeated back to him. T.V. has no sensitivity to high pitched sounds and was able to hear
when I rubbed my fingers close to his ears.
Upon exam of the lymph nodes, I wasnt able to palpate which is a normal finding
in the elderly individual (Lewis, 2011). When palpating the head, neck, and underarms for
enlarges lymph nodes, none were felt in the occipital, pre-auricular, cervical, supraclavicular, or
axillary areas.
Upon assessment of the thorax, the ribs were intact and there was no obvious
trauma to chest. The shoulders are even and the spinal column is straight without evidence of
scoliosis. Upon auscultation of the lung fields, clear lung sounds are heard bilaterally and T.V
has a respiratory rate of 12 per minute. His breathing was unlabored. There were no signs of a
flail chest or abdominal breathing. Loss of elasticity, stiffening, and decreased movement of the
chest wall can cause breathing issues and weak muscles in the elderly adult (Lewis, 2011). T.V.
didnt display any obvious respiratory distress and upon exam was able to adequately breathe in
and out.
ASSESMENT 5
Cardiac wise, J.W. has a blood pressure of 110 millimeters of mercury (mmHg) over 60
mmHg and a heart rate of 76 beats per minute. The range for systolic blood pressure is equal to
or less than 120 mmHg and diastolic equal to or less than 80 mmHg. Normal heart rate is 60-100
beats per minute. (Lewis, 2011). Peripheral pulses in the temporal, carotid, brachial, radial,
posterial-tibial, and pedal areas. All peripheral pulse were +3 bilaterally. The femoral and
popliteal pulses were not assessed. Upon asculation of the heart, all heart sounds were present
and didnt hinder any abnormalities. T.V. currently has no chest pain, and no signs or symptoms
of a myocardial infarction. He is currently resting comfortably in his recliner chair. All of his
extremities are pink and have a capillary refill of less than two seconds. No edema is present
bilaterally in the lower legs.
The abdomen is soft, non-distended, and non-tender. Bowel sounds are present in
all 4 quadrants. There is little abdominal fat present. No decreased peristalsis is present, however,
decreased peristalsis is a common feature of the gastrointestinal system of the aged adult (Lewis,
2011).
When assessing the musculoskeletal system, T.V. is able to move all extremities
without pain or resistance. Lewis states that common musculoskeletal system issues that can
arise in the aged adult are weak muscle structure, rigid musculature, and decreased reflexes,
however, T.V. has excellent reflexes, and maintains muscle tone. He has no complaints regarding
his back and neck or extremities. He feels that he is able to efficiently move around whenever he
wants to.
When assessing the central nervous system, T.V. is alert and oriented to person, place,
time, and situation. He demonstrates no level of confusion. Upon assessment of his nerve
ASSESMENT 6
function, he showed adequate olfactory nerve function. The optic nerve was tested by having
T.V. read a section of the newspaper. T.V. was also able to effectively perform the six cardinal
functions of gaze test which showed function of the oculomotor, trochlear, and abducens nerves.
T.Vs trigeminal nerve was intact. The whisper test was performed later in the assessment and
showed optimal auditory nerve function. He was able to swallow and cough which showed a
properly functioning glossopharyngeal nerve. Upon pressing down on the shoulders while the
patient tried to shrug the shoulders up demonstrated adequate spinal nerve functioning.
Shrugging of the shoulders shows spinal nerve functioning. T.V. also was able to stick out his
tongue and move it side to side which demonstrated that the hypoglossal nerve was intact. He
was also able to stick out his tongue and move it from side to side which showed me that his
hypoglossal nerve was intact.
Lewis states that common changes that occur in the nervous system of the aging adult are
altered mental functioning within the brain, loss of neurons, decreased reaction time, slowed
deep tendon reflexes, however T.V. had positive deep tendon reflexes bilaterally.
Communication
T.V. wears glasses during reading because he has presbyobia. He has no neurological
impairments. Regarding assistive devices, T.V. wears hearing aids in both ears. T.V. speaks
English fluently, and can adequately read and write.
Functional Assessment
T.V. states that he doesnt need assistance with activities of daily living. He states that he
has been able to complete activities such as bathing, feeding, cooking, cleaning, preparing meals,
and toileting without any issues. T.V. has a steady gait, uses no assistive devices to ambulate,
ASSESMENT 7
and is able to remain physically mobile. He does state however, that some strenuous activities
such as mowing the grass and shoveling the snow are becoming difficult because of his age and
decreased physical endurance. However, he states that the development from which he lives in
hires a contractor to do these duties, and he just pays $50 a month for this service. In addition, he
states that although his driveway gets plowed, his sidewalk doesnt. But he states that he doesnt
need to worry about that because his 23 year old grandson voluntarily comes to shovel it for him.
The Katz Activities of Daily Living ranges from 0-6 with higher scores indicating more
independence for that individual (Weber & Kelly, 2010). T.V. scores a 6 on this scale because he
remains fully independent and doesnt need assistance in ADLs. Regarding the Lawton Scale for
Instrumental Activities of Daily Living which scores are from 8-28, with a lower score indicating
more independence (Weber & Kelly, 2010) T.V is a 10 because of decreased physical endurance
related to aging.


Nutritional Assessment
T.V. is 6ft tall and weighs 210 lbs. His BMI is 28.48 which is considered overweight
(Lewis, 2011). Regarding caloric and nutrient needs, T.V should be consuming at least 2,000
calories a day to maintain his weight. His diet should also be low in fat and sodium, carb
consistent, and high in fiber. His diet should also contain plentiful fruits and vegetables. In
addition, his diet should contain an adequate amount of protein.
Regarding food recall, T.V. states that he drank a cup of decaffeinated coffee and a slice
of white bread with peanut butter for breakfast. For lunch, he stated that he consumed a plate of
spaghetti and a tomato salad that has contained cut peppers, cucumbers, and tomatoes. For fluid
ASSESMENT 8
intake during lunch, he consumed three cups of water. For dinner, he ate lean white chicken with
potatoes and a tomato salad, and consumed three cups of water.
The Determine tool is a checklist designed to show the warning signs that could
affiliated with elderly adults at risk for poor nutrition (The Nutrition Screening Initiative, n.d.).
Part of the Determine tool describes the disease and then relates it to how the person may or may
not change the way they eat. T.V. doesnt feel that his disease process has changed what food he
is consuming on a regular basis. T.V. feels that he is getting older, and deserves to eat food that
he enjoys. Another part of the Determine tool discusses topics such as eating poorly or eating
few meals during the day. T.V. does occasionally eat fewer than two meals a day so he would
score a three on the Determine tool.
The Determine tool also addresses any tooth loss which doesnt apply to T.V. All his teeth
are intact. In addition to tooth loss, economic hardship is another topic of this tool. T.V. states
that he is financially stable due to retirement benefits and also because his son is a millionaire,
and has paid off his car, mortgage, and other finances. The next topic is social contant in which
T.V> feels that this area doesnt apply to him. He states that he is blessed with great family and
friends and feel connected to them. The next Multiple medicines is the next area and this does
relate to him because he does take three or more prescribed medications.
The Involuntary weight loss or weight gain area does not relate because his weight has
been the same for almost 13 years. The last two sections of the Determine screen do not refer
to J.W. because he needs no assistance with self-care and is under the age of 80 (The Nutrition
Screening Initiative, n.d.).

ASSESMENT 9

Dysphagia Assessment
Regarding swallowing difficulties, T.V. states that he has none. He states that sometimes
food will go down the wrong pipe, but states that he is able to cough to relieve this discomfort.
Fall Risk
T.V. has no history of any falls and has adequate strength and balance when standing and
moving. The Get Up and Go Test was performed on assessment. T.V. was instructed to sit with
his back to the chair and have proper footwear on his feet. He was also to have his arms resting
the sides of his chair. He was then told to stand up and walk 10 feet, turn around, and then sit
back in that same chair. He was able to perform this test in 8 seconds which was within normal
time for completion.
Elimination
T.V. has no complaints regarding bowel and bladder function. He states that he has no
variations from his normal pattern, and doesnt use any assistive devices.
Sleep
Regarding sleep, T.V. states that he goes to bed around 7 p.m. and then wakes up at 2 a.m
giving him 8 hours of sleep. At 2 a.m., he goes to Snyders Restaurant in Shamokin for breakfast
which consists of a cup of decaffeinated coffee and a slice of toast with butter. Typically, he
states that he stays at the restaurant until 4a.m -5a.m., and then goes back home and reads the
morning newspaper. He then states that he takes a nap until noon and then awakes to eat lunch.
The factors that affect his sleep include eating prior to napping. T.V. states that he doesnt take
any medications to promote sleep, and often either reads or watches television to help him sleep.

ASSESMENT 10

Wellness and Health Promotion
Regarding health promotion strategies, T.V, visits his primary care provider regularly. He
also gets colonoscopy screenings, and keeps up to date on his immunizations. He also wears his
seatbelts while operating his vehicle, and drinks alcohol rarely. T.V. also doesnt engage himself
in any illicit drug use. The factors that impede health promotion include denial of any health
issues. Although he has a cardiac history and is a borderline diabetic,he is reluctant to exercise
and continues to eat food that is high in sodium, fats, and sugar which can all further aggravate
his health status. Although, T.V. does remain current on his flu and pertussis vaccine. Regarding
his own self rating of his health status, T.V. states that he cant complain, and is happy with his
health.
Medications and/or Alternative Therapies
Regarding prescription medications, T.V. takes Lopressor 25 mg, Lisinopril 5 mg,
Torevestatin 40 mg, Aspirin 81 mg daily. In addition, he is prescribed Meformin 500 mg twice
daily with food. Regarding over the counter medications, T.V. takes aspirin occasionally. T.V.
also engages in alternative medicine with includes taking a cinnamon and a multivitamin pill
daily. T.V. states that these therapies are used because cinnamon has been known to improve
memory, and a multivitamin gives his body essential vitamins and minerals that he may not get
from his regular diet. Regarding effectiveness of his medications, T.V. states that this blood
pressure is within his doctors recommendation of 135/80 or lower. He also states that his
cholesterol level has been controlled and is below 100, and his A1C is less than 7.
T.V. states that he has no problems adhering to his medications. He states that he
organizes his medications by a pill box and takes his medications on time every day. He also
ASSESMENT 11
states that he contacts his doctor if he has any questions or concerns regarding his prescribed
medications and knows the adverse side effects of his medications. He states that he also knows
when he should contact his doctor if there adverse effects related to his medication.
Typical Day
T.V. states that his day consists of waking up at 2 a.m. to go to Snyders Restaurant for
breakfast. He states that he typically stays at the restaurant until 4a.m 5 a.m. then goes home to
read the morning newspaper. He then falls asleep on the couch, and gets up at noon to eat lunch.
After lunch he states that he drives to Shamokin to go to the Mother Cabrini Church for rosary at
3 p.m. and stays there til 4p.m or 5 p.m. He then states that he then drives home, eats dinner, and
goes to bed at 7 p.m. In addition, T.V. states that during the summer, between lunches and going
to the church, he will visit Knoebels to get a chocolate ice cream and sit on the park benches to
watch people go by.
Psychological Assessment
T.V.s perception of advancing age is accepting. He states that he isnt as active as he
once was, but feels happy and blessed. He states that he cant complain of nothing. Regarding
losses, he feels he lost no independence but feels that his appetite and activity level has
decreased. He also stated that another loss he had was of his girlfriend. He stated that she passed
away 10 years ago, and died of cancer. He said that since then, he lost some social interaction
with the real world because she enjoyed traveling and going out to new places, and it has since
caused him to get lonely at times.
T.V. states that he doesnt have much stress, but has been recently stressed because
people stole copper wiring and pipes out of his previous home that he was trying to sell in
Shamokin. He stated that this incident got him upset because he put a lot of money into the
ASSESMENT 12
home, and didnt receive a profit back when it sold. Regarding advance directives, T.V. doesnt
have any.
Sociological Assessment
T.Vs typical activities include going to Knoebels for an hour in the afternoon to get a
chocolate ice cream cone and to sit on a bench to watch people. In addition, other activities that
he likes includes going to local restaurants with close family and friends for lunch and dinner,
and going every morning at 2 a.m. to eat breakfast at Snyders Restaurant. In addition, he visits
the Mother Cabrini Church in Shamokin, PA.
Regarding sexuality, T.V prefers not to answer. Regarding support systems, T.Vs support
system includes God, members of the Mother Cabrini Church, his 6 grandchildren, 2 sons and 2
daughters, as well as people in the community.
Regarding religion, T.V is Roman Catholic and practices his religion frequently. He goes
to church every day, and offers spiritual care to the sick and prisoners. T.V. is also 100% Italian
descent and enjoys his cultural practices such as eating pastas and listening to Luciano Pavarotti.
Regarding community resources and agency involvement, T.V isnt part of any of these
resources. However, T.V is a member of the Knights of Columbus in Shamokin, PA,

Environment
Regarding T.Vs living environment, it is very suitable for him. He lives in a one story
brand new home in Elysburg, PA. The home is located in a safe development in which he is
friends with this neighbors. There are side rails in the bathroom, carpeting in all rooms besides
the kitchen, and there are no scatter rugs present in the home. In addition, he has carbon
monoxide and fire detectors in the home that are working properly.
ASSESMENT 13
Regarding potential hazards in T.Vs living environment, T.Vs house is located on a very
steep hill that is significantly icy during the winter. Therefore there is great potential for a fall.
Analysis: problem identification
T.Vs top problem is related to his heart condition. Since he had an acute MI, priority
definitely involves makes sure that his heart has adequate blood flow. In addition, T.V is at risk
for falls related to his very icy driveway and also due to aging. T.V. also doesnt follow his
diabetic regimen closely, and needs to be evaluated for diabetic neuropathy, kidney failure, and
yearly eye exams. In addition, special importance needs to be addressed to the skin which from
aging can be less durable and more susceptible to damage.
NANDA Nursing Diagnoses
Risk for decreased cardiac output r/t acute MI
Risk for falls related to changes associated with aging
Imbalanced nutrition: diet high in fat and sodium
Risk for injury r/t decreased vision acuity and hearing loss
Risk for impaired skin integrity r/t changes associated with aging
Teaching and Interventions
T.V. needs to educated about maintaining his health especially in regards to his heart,
increased risk for falls, imbalanced nutrition that can have serious consequences in relation to his
heart, risk for injury related to aging, and also risk for skin integrity. Regarding his heart, it is
ASSESMENT 14
essential that T.V. knows that a low sodium, low fat, high fiber duet is beneficial to maintaining a
healthy heart.
T.V. should be taught also the increased health risks of consuming foods with too high of
sodium which can manifest a stroke which he has a family history of. T.V. also needs to be taught
to wear non-skid shoes, and to always watch his environment for potential hazards. He should
also be taught to remove any scatter rugs that he has in his home, and use the side rails. He
should also be advised to implement lights when moving around his home and especially if he
has to get out of bed at night. T.V. should also be taught to shift his weight frequently while in a
chair or in bed to prevent skin breakdown.
Evaluation
I feel T.V. was able to understand the teaching that was taught to him. He was able to
acknowledge that he needs to regulate his diet better which is a starting point to eating a diet that
is healthier for his heart. In relationship to other teachings that were addressed, T.V. understood
all aspects. He nodded his head, and maintained eye contact throughout the teachings. He also
asked questions as the assessment ended which showed me that he was interested in what he was
taught. I believe that T.V. from this assessment will make minor changes in his life such as
reducing the amount of sodium he puts on his food, etc and will continue to promote his health.



ASSESMENT 15

References
Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2010). Medical-surgical
nursing: Assessment and management of clinical problems. (8th edition ed.). St.
Louis,Missouri: Elsevier.
The Nutrition Screening Initiative (n.d.). Determine your nutritional health. Retrieved from
http://www.healthcare.uiowa.edu/igec/tools/nutrition/determineNutrition.pdf
Weber, J. R., & Kelley, J. (2010). Health assessment in nursing. (4 ed.). Wolters Kluwer Health
Lippincott Williams & Wilkin.