Patient Profile H.J., a 74-year-old African American male, is a retired army military officer. His wife of over 50 years passed away four years ago. He has four daughters and two sons who are all grown and married. He has fourteen grandchildren with a great-grandchild on the way. His son brought him to the health care provider today because he is concerned his father has been more forgetful and is losing weight. H.J. has a history of coronary artery disease that is being managed with metoprolol XL (Lopressor) and aspirin. Subjective Data Patient states, “I am doing fine. I just miss my wife and the fine meals she used to make.” His son says he has noticed his dad has been tightening his belt up to two notches. Patient states, “My children are worrying unnecessarily.” What level of assessment do you need to perform? How will your assessment be different from the assessment performed by the health care provider? Case Study Progress Objective Data Physical Examination Blood pressure 136/80, pulse 62, respiratory rate 16, temperature 97.6° F Height 5’10”, weight 158 lb, BMI 22.7 Neurological: Alert and oriented to person, place, and time. Pupils equal and reactive to light, grips equal strength. Respiratory: Lung sounds clear in all fields. Cardiovascular: Heart sounds regular in rate and rhythm; S1 and S2 heard; no murmurs auscultated. Radial pulse and pedal pulses present. Gastrointestinal/Nutrition: Bowel sounds present and active in all four quadrants. Abdomen soft and nondistended, nontender. Skin: Pink, warm,and dry; skin turgor good, no tenting, cap refill < 2 seconds; no skin breakdown on bony prominences. Has healing abrasions noted on both knees. GU/Elimination: Per patient, his last bowel movement was early in the morning. He goes every 2-3 days and describes his stools as medium-size and brown. States he is urinating without difficulty. Musculoskeletal: States he is able to walk around the block without difficulty; his son says that the knees are scraped from a recent fall.3. Based on your assessment, you are concerned about H.J.’s functional abilities and decide to evaluate him further. What types of functional screening tools would be appropriate for H.J.? 4. What is the difference between activities of daily living and instrumental activities of daily living? 5. You decide to use the Mini-Cog to evaluate if H.J. has a neurocognitive disorder. Describe the administration and interpretation of the Mini-Cog. 6. Falls are associated with subsequent decline in functional status. Describe how to use the "time to get up and go" test to screen H.J. for gait instability and risk of falls. Case Study Progress H.J. is able to complete the "time to get up and go" test in 22 seconds. His performance on the Mini-Cog does not reveal any potential deficits; when asked if he feels sad or depressed, he states that he does not. 7. What nursing diagnoses and problems do you feel exist for H.J ?
