Geriatric Patient Assessment
Temperature . . fairly expected for age), starting to need a little assistance here and there with daily tasks (not outside of norm for age, though)
Pulse
Respiration
Blood Pressure: 110/70
Pulse Oximetry: 97% on room air
General Appearance: Fairly good, decently nourished. Non-toxic, Ambulatory female
Mental Status: Patient is alert and fully oriented times 3 . . . .Glasgow coma scale is
Abdomen: Benign
Heart: Mild tachycardia
Lungs: Clear, no noticed issues
Extremities: Pulses are symmetric and seem to be intact
Known Issues/Comorbidities: Type II (Adult Onset) Diabetes, family history of heart disease and arthritis
2A) MMSE will be attached
Pulled from: http://www.dementiatoday.com/wp-content/uploads/2012/06/MiniMentalStateExamination.pdf
2B) KATZ Index will be attached
Pulled from http://micmrc.org/system/files/11.2-ADL.pdf
Vitals fairly in line what is expected a normal for patient of this age, family/patient history of type II diabetes but fairly well controlled, mild arthritis but decently controlled, no sign of heart disease despite family history
4) Patient is putting on a little weight, lives a mostly sedentary lifestyle (but not abnormally so for age bracket), diet a bit substandard based on what is self-reported
5) See goals below where abnormal challenges are listed
6) Four interventions would be:
- Better diet (to keep weight and blood sugar in check)
- Better drug adherence (blood sugar/arthritis management)
Abnormal Changes Observed:
• Progressing arthritis -- Use pharmacological AORD interventions and calcium supplements in short-term . . . keep up scans and metrics over long-term (WebMD, 2017)
• Progressing type II diabetes -- Patient needs to use drugs to regulate blood sugar and get heart rate up via exercise in short-term . . . track A1C and blood sugar over long-term to monitor progress. (NDEI, 2017).
• Weight gain -- Find a way to balance out decrease in calories burned and lack of change in calories taken in (exercise, diet, combo of the two) in short-term . . . ramp up for back off of interventions in long-term based on results (Reese, 2017).
• Fall in blood pressure as compared to prior measurements -- Keep track and use drugs as a means to raise/lower as needed in short-term -- monitor blood pressure at home and during visits over long-term so adjustments can be made if needed (Mayo, 2017).
References
Mayo. (2017). Low blood pressure (hypotension) Treatments and drugs - Mayo Clinic. Mayo Clinic. Retrieved 4 April 2017, from http://www.mayoclinic.org/diseases-conditions/low-blood-pressure/basics/treatment/con-20032298
NDEI. (2017). Diabetes Management Guidelines for Elderly ADA/AGS | NDEI. ndei.org. Retrieved 4 April 2017, from http://www.ndei.org/ADA-AGS-diabetes-older-adults-2012.aspx.html
Reese, H. (2017). Nutrition for the Elderly - Diet & Exercise | HealthCentral. Healthcentral.com. Retrieved 4 April 2017, from https://www.healthcentral.com/article/nutrition-for-the-elderly
WebMD. (2017). Arthritis Treatment Options. WebMD. Retrieved 4 April 2017, from http://www.webmd.com/osteoarthritis/guide/options-basics#1
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