Running Head: GERONTOLOGY PROCESS PAPER
Nursing Process for a Geriatric Needs Patient
Laura Ruckman
Kent State University College of Nursing
1
GERONTOLOGY PROCESS PAPER
2
Client Profile
IK is a 72 year old female who was admitted to the hospital on March 2, 2012 for a
primary diagnosis of bilateral knee replacements and secondary diagnosis of Chronic Obstructive
Pulmonary Disease and Congestive Heart Failure. IK is 55.4 kilograms tall and weighs 193
pounds. She is allergic to Niacin and Augmentin. IK said that she breaks out in hives and forms
a rash all over her body. She was married for 52 years until her husband past away last year
from small cell lung cancer. IK and her husband had two children and now they have 5
grandchildren with 2 great-grandchildren. IK is accompanied today with one of her daughters
that live in Maryland. The other daughter is coming into town later on this evening from Dallas.
IK worked as an English teacher for almost 30 years and she attended The Ohio State University.
She later went back and got her master’s from Kent State University. IK said that she loved
teaching more than anything in the world. Her daughter said that she was very strict when it
came to school when they were growing up. IK would not let her children go out with their
friends or do anything until their school work was finished. She also stressed the importance of
college to her children. IK said the whole point of having children was so they could live a
better life than what they had. She said that her and husband did not want to grow old having to
see their children struggle trying to make it on a daily basis. IK’s daughter then wanted to talk
out in the hallway. Her daughter said that IK had not fully got over losing her husband last year
then to top everything off IK lost her brother that she was close to this past fall. Her daughter
said that ever since she lost her brother IK’s health has been rapidly declining. She then said the
doctor has recommended that IK go to a skilled nursing facility. The daughter said that she was
waiting for her sister to come in this evening to break the news to IK that she can no longer live
on her own. She said they do not have long to decide because IK’s insurance was only going to
GERONTOLOGY PROCESS PAPER
3
allow her to stay in the hospital for two more days. The daughter said that she and her sister
have appointments tomorrow for a couple of different skilled nursing facilities around the area.
Past medical and surgical history
IK was a smoker for 32 years until she quit in the fall of 2002. She would smoke one to
two packs daily depending on what she was doing. IK got diagnosed with Congestive heart
failure (CHF) in 2007 followed by Chronic Obstructive Pulmonary Disease (COPD) in 2008.
She got diagnosed with hypertension after her first heart attack in the spring of 1998. IK said
that she has always had an anxiety problem since she was younger but started to get worse as she
got older. She also got diagnosed with rheumatoid arthritis in the fall of 2007.
Medical Diagnosis
Pathophysiology
The primary indication for total knee arthroplasty is to relieve pain caused by severe
arthritis. The pain should be significant and disabling. Night pain is particularly distressing. If
dysfunction of the knee is causing significant reduction in the patient's quality of life, this should
be taken into account. Correction of significant deformity is an important indication but is rarely
used as the primary indication for surgery. Roentgenographic findings must correlate with a clear
clinical impression of knee arthritis (Black and Hawk, 2009). Patients who do not have
significant loss of joint space tend to be less satisfied with their clinical result following TKA.
Exhaust all conservative treatment measures before considering surgery. Knee replacement has a
finite expected survival that is adversely affected by activity level. Generally, it is indicated in
older patients with more modest activities. It is also clearly indicated in younger patients who
have limited function because of systemic arthritis with multiple joint involvement. Young
GERONTOLOGY PROCESS PAPER
4
patients requesting knee replacement, especially those with posttraumatic arthritis, are not
excluded by age but must be significantly disabled and must understand the inherent longevity of
joint replacement. Movement of the knee joint can be classified as having 6 degrees of freedom:
3 translations and 3 rotations (Black and Hawk, 2009). Translations include anterior/posterior,
medial/lateral, and inferior/superior; rotations include flexion/extension, internal/external, and
abduction/adduction. Movements of the knee joint are determined by the shape of the
articulating surfaces of the tibia and femur and the orientation of the 4 major ligaments of the
knee joint. The anterior and posterior cruciate ligaments and the medial and lateral collateral
ligaments serve as a 4-bar linkage system. Knee flexion/extension involves a combination of
rolling and sliding called femoral rollback, which is an ingenious way of allowing increased
ranges of flexion. Because of asymmetry between the lateral and medial femoral condyles, the
lateral condyle rolls a greater distance than the medial condyle during 20 degrees of knee flexion
(Black and Hawk, 2009). This causes coupled external rotation of the tibia, which has been
described as the screw-home mechanism of the knee that locks the knee into extension. The
primary function of the medial collateral ligament is to restrain valgus rotation of the knee joint,
with its secondary function being control of external rotation. The lateral collateral ligament
restrains varus rotation and resists internal rotation. The primary function of the anterior cruciate
ligament (ACL) is to resist anterior displacement of the tibia on the femur when the knee is
flexed and control the screw-home mechanism of the tibia in terminal extension of the knee. A
secondary function of the ACL is to resist varus or valgus rotation of the tibia, especially in the
absence of the collateral ligaments. The ACL also resists internal rotation of the tibia. The main
function of the posterior cruciate ligament (PCL) is to allow femoral rollback in flexion and
resist posterior translation of the tibia relative to the femur. The PCL also controls external
GERONTOLOGY PROCESS PAPER
5
rotation of the tibia with increasing knee flexion. Retention of the PCL in total knee replacement
has been shown biomechanically to provide normal kinematic rollback of the femur on the tibia.
This also is important for improving the lever arm of the quadriceps mechanism with flexion of
the knee. Movement of the patellofemoral joint can be characterized as gliding and sliding.
During flexion of the knee, the patella moves distally on the femur. This movement is governed
by the attachments of the patellofemoral joint to the quadriceps tendon, ligamentum patellae, and
the anterior aspects of the femoral condyles. The muscles and ligaments of the patellofemoral
joint are responsible for producing extension of the knee (Black and Hawk, 2009). The patella
acts as a pulley in transmitting the force developed by the quadriceps muscles to the femur and
the patellar ligament. It also increases the mechanical advantage of the quadriceps muscle
relative to the instant center of rotation of the knee. The mechanical axis of the lower limb is an
imaginary line through which the weight of the body passes. It runs from the center of the hip to
the center of the ankle through the middle of the knee. This axis is altered in the presence of
deformity and must be reconstituted at surgery, which allows normalization of gait and protects
the prosthesis from eccentric loading and early failure (Black and Hawk, 2009).
COPD is characterised by chronic inflammation of the airways, lung tissue and
pulmonary blood vessels as a result of exposure to inhaled irritants such as tobacco smoke. The
inflammatory markers sustain the inflammatory process and lead to tissue damage as well as a
range of systemic effects (Black and Hawk, 2009). The chronic inflammation is present from the
outset of the disease and leads to various structural changes in the lung which further perpetuate
airflow limitation. Airway remodelling in COPD is a direct result of the inflammatory response
associated with COPD and leads to narrowing of the airways. Three main factors contribute to
this: peribronchial fibrosis, build up of scar tissue from damage to the airways and over-
GERONTOLOGY PROCESS PAPER
6
multiplication of the epithelial cells lining the airways (Black and Hawk, 2009). Emphysema is
also associated with loss of lung tissue elasticity, which occurs as a result of destruction of the
structures supporting and feeding the alveoli. This means that the small airways collapse during
exhalation, impeding airflow, trapping air in the lungs and reducing lung capacity. Smoking and
inflammation enlarge the mucous glands that line airway walls in the lungs, causing goblet cell
metaplasia and leading to healthy cells being replaced by more mucus-secreting cells (Black and
Hawk, 2009). Additionally, inflammation associated with COPD causes damage to the
mucociliary transport which is responsible for clearing mucus from the airways. Both these
factors contribute to excess mucus in the airways which eventually accumulates, blocking them
and worsening airflow.
Congestive heart failure (CHF) is a complex clinical syndrome that can result from any
functional or structural cardiac disorder that impairs the ventricle’s ability to fill with or eject
blood. The syndrome of CHF arises as a consequence of an abnormality in cardiac structure,
function, rhythm, or conduction. In developed countries, ventricular dysfunction accounts for
the majority of cases and results mainly from myocardial infarction (systolic dysfunction),
hypertension (diastolic and systolic dysfunction), or in many cases both (Black and Hawk, 2011).
Degenerative valve disease, idiopathic cardiomyopathy, and alcoholic cardiomyopathy are also
major causes of heart failure (Black and Hawk, 2011). Heart failure often occurs in elderly
patients who have multiple comorbid conditions, for example, angina, hypertension, diabetes,
and chronic lung disease. Some common comorbidities such as renal dysfunction are
multifactorial which is decreased perfusion or volume depletion from overdiuresis.
The pathogenesis of essential hypertension is multifactorial and highly complex. Multiple
factors modulate the blood pressure (BP) for adequate tissue perfusion and include humoral
GERONTOLOGY PROCESS PAPER
7
mediators, vascular reactivity, circulating blood volume, vascular caliber, blood viscosity,
cardiac output, blood vessel elasticity, and neural stimulation (Black and Hawk, 2009). A
possible pathogenesis of essential hypertension has been proposed in which multiple factors,
including genetic predisposition, excess dietary salt intake, and adrenergic tone, may interact to
produce hypertension. Although genetics appears to contribute to essential hypertension, the
exact mechanism has not been established. The natural history of essential hypertension evolves
from occasional to established hypertension. After a long invariable asymptomatic period,
persistent hypertension develops into complicated hypertension, in which target organ damage to
the aorta and small arteries, heart, kidneys, retina, and central nervous system is evident. The
progression begins with prehypertension in persons aged 10-30 years (by increased cardiac
output) to early hypertension in persons aged 20-40 years (in which increased peripheral
resistance is prominent) to established hypertension in persons aged 30-50 years, and, finally, to
complicated hypertension in persons aged 40-60 years (Black and Hawk, 2009). One mechanism
of hypertension has been described as high-output hypertension. High-output hypertension
results from decreased peripheral vascular resistance and cardiac stimulation by adrenergic
hyperactivity and altered calcium homeostasis. A second mechanism manifests with normal or
reduced cardiac output and elevated systemic vascular resistance due to increased vasoreactivity.
Another (and overlapping) mechanism is increased salt and water reabsorption by the kidney,
which increases circulating blood volume (Black and Hawk, 2009).
Anxiety is due to a known or unrecognized medical condition. Substance-induced anxiety
disorder (over-the-counter medications, herbal medications, substances of abuse) is a diagnosis
that often is missed (Black and Hawk, 2009). Genetic factors significantly influence risk for
many anxiety disorders. Environmental factors such as early childhood trauma can also
GERONTOLOGY PROCESS PAPER
8
contribute to risk for later anxiety disorders. The debate whether gene or environment is primary
in anxiety disorders has evolved to a better understanding of the important role of the interaction
between genes and environment (Black and Hawk, 2009). Some individuals appear resilient to
stress, while others are vulnerable to stress, which precipitates an anxiety disorder. Anxiety
disorders appear to be caused by an interaction of biopsychosocial factors, including genetic
vulnerability, which interact with situations, stress, or trauma to produce clinically significant
syndromes. In the central nervous system (CNS), the major mediators of the symptoms of
anxiety disorders appear to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric
acid (Black and Hawk, 2009). Other neurotransmitters and peptides, such as corticotropinreleasing factor, may be involved (Black and Hawk, 2009). Peripherally, the autonomic nervous
system, especially the sympathetic nervous system, mediates many of the symptoms.
Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of
heart muscle secondary to prolonged ischemia. This usually results from an imbalance in oxygen
supply and demand, which is most often caused by plaque rupture with thrombus formation in a
coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium
(Black and Hawk, 2009). The spectrum of myocardial injury depends not only on the intensity of
impaired myocardial perfusion but also on the duration and the level of metabolic demand at the
time of the event. The damage in the myocardium is essentially the result of a tissue response
that includes apoptosis (cell death) and inflammatory changes. The typical myocardial infarction
initially manifests as coagulation necrosis that is ultimately followed by myocardial fibrosis.
Contraction-band necrosis is also seen in many patients with ischemia. This is followed by
reperfusion, or it is accompanied by massive adrenergic stimulation, often with concomitant
myocytolysis (Black and Hawk, 2009).
GERONTOLOGY PROCESS PAPER
9
Rheumatoid arthritis is best characterized as an immune mediated inflammatory disease
(IMID) (Black and Hawk, 2009). Within a framework that recognizes both immunological
activation and inflammatory pathways, we can begin to evaluate the multiple components of
disease initiation and propagation. This framework highlights that once initiated and even after a
putative trigger may be eliminated, there are feed forward pathways that result in an autoperpetuating process. The synovium, in normal joints, is a thin delicate lining that serves several
important functions. The synovium serves as an important source of nutrients for cartilage since
cartilage itself is avascular (Black and Hawk, 2009). In addition, synovial cells synthesize joint
lubricants such as hyaluronic acid, as well as collagens and fibronectin that constitute the
structural framework of the synovial interstitium. Synovial lining or intimal layer: Normally,
this layer is only 1-3 cells thick. In RA, this lining is greatly hypertrophied (8-10 cells thick)
(Black and Hawk, 2009) . Primary cell populations in this layer are fibroblasts and macrophages.
Subintimal area of synovium: This is where the synovial blood vessels are located; this area
normally has very few cells. In RA, however, the subintimal area is heavily infiltrated with
inflammatory cells, including T and B lymphocytes, macrophages, mast cells, and mononuclear
cells that differentiate into multinucleated osteoclasts. The intense cellular infiltrate is
accompanied by new blood vessel growth (angiogenesis). In RA, the hypertrophied synovium
(also called pannus) invades and erodes contiguous cartilage and bone. As such, it can be thought
of as a tumor-like tissue, although mitotic figures are rare and, of course, metastasis does not
occur (Black and Hawk, 2009). Composed primarily of type II collagen and proteoglycans, this
is normally a very resilient tissue that absorbs considerable impact and stress. In RA, its
integrity, resilience and water content are all impaired. This appears to be due to elaboration of
proteolytic enzymes (collagenase, stromelysin) both by synovial lining cells and by chondrocytes
GERONTOLOGY PROCESS PAPER
10
themselves. Cytokines including IL1 and TNF drive the generation of reactive oxygen and
nitrogen species and while increasing chondrocyte catabolic pathways and matrix destruction,
also inhibit new cartilage formation. Polymorphonuclear leukocytes in the synovial fluid may
also contribute to this degradative process. Composed primarily of type I collagen, bony
destruction is a characteristic of RA. This process is primarily driven by the activation of
osteoclasts. Osteoclasts differentiate under the influence of cytokines especially the interaction
of RANK with its ligand (Black and Hawk, 2009). The expression of these are driven by
cytokines including TNF and IL1, as well as other cytokines including IL-17. There may also be
a contribution to bony destruction from mediators derived from activated synovial cells. The
synovial cavity is normally only a "potential" space with 1-2ml of highly viscous (due to
hyaluronic acid) fluid with few cells. In RA, large collections of fluid ("effusions") occur which
are, in effect, filtrates of plasma (and, therefore, exudative - i.e., high protein content). The
synovial fluid is highly inflammatory. However, unlike the rheumatoid synovial tissue in which
the infiltrating cells are lymphocytes and macrophages but not neutrophils, in synovial fluid the
predominant cell is the neutrophil (Black and Hawk, 2009).
Concept Care Map
See concept care map.
Running Head: GERONTOLOGY PROCESS PAPER
Medications
11
Student Name: Laura Ruckman Client Initials: IK Date: March 8, 2012 Age: 72 Gender: F
Tiotropium bromide-18mcg PO daily
Admit Date: March 2, 2012 Code Status: Full Allergies: Augmentin and Niacin
Albuterol – 2.5mg PO qid
Diet: Cardiac Diet Activity: Up as tolerated Braden Score: 20/23
Lab Values/Diagnostic Test
Results
Na: 144
Atenolol – 100mg PO bid
Furosemide – 20mg PO daily ac
Prednisone – 10mg daily PO with meal
Admitting Diagnoses/Chief Complaint
Bilateral Knee Replacements
BUN: 12
K: 4.6
Creatinine: 0.80
Morphine sulfate – IV:2mg q2hrs prn
Ativan – IV injection: 0.5mg q6hrs prn
CL: 100
Glucose: 169
Zofran – IV: 4mg q6hrs prn
T: 98.8 P: 93 R: 18 B/P: 131/98 O2: 95% on 2 Liters A&Ox3 Pain: 6/10
Apical: 90 PERRLA Speech: Clear
WBC: 9.2
Leflunomide – 20mg daily PO
Lungs are diminished bilaterally with wheezing present.
Hemoglobin: 9.9
Enoxaparin – 30mg SC q12hrs
Cefpodoxime proxetil – 200mg PO bid
Productive cough with white/yellow sputum
Strong radial pulses but had weak pedal pulses
Lactulose – 30ml PO daily prn
Pt had plus 1 edema in lower extremities
IV Sites/Fluids/Rate
#24 LH 3/6
Heplok
Bowel sounds hypoactive with abdomen distention but non tender
Pt states: “I have always had a problem with constipation”.
Had moderate amount of serosanguineous drainage coming out of left knee
from bilateral knee surgery and patient reports that they are sore.
Past Medical/Surgical History
Smoker – 1-2 pks daily
COPD
CHF
Hypertension
Anxiety
MI
Rheumatiod Arthritis
Hematocrit: 34.0
Platelets: 196
BUN/CREA: 15
RBC: 3.40
CO2: 28
Treatment
2L of continuous O2
Pt had thickening and yellowing on nails bilaterally.
HOB 30 degrees
Pt stated: “I use a walker to move around when I get up but sometimes I need
some assistance.”
Incentive Spirometer q2hrs
Pt has a bed alarm that requires assistance of one person.
ABD pads on bilateral knees with
paper tape qshift
Pt reports feeling lonely because her family lives out of state and her
husband past away last year.
Ice to both knees after therapy &
prn
Pt reports feeling upset because of the possibility of going to a skilled
nursing facility for rehab from surgery.
Ted hose on when out of bed and
off at night & assess heels
Running Head: GERONTOLOGY PROCESS PAPER
12
Assessment Data
General Survey
On March 8, 2012 at 3pm, the following assessment was taken for IK. IK had a pulse of
93 beats per minute, a respiratory rate of 18 breaths per minute, a blood pressure of 131/98
mmHg, a temperature of 98.8° Fahrenheit, and an O2 saturation rate of 95% on 2 liters of oxygen.
IK reported a pain level of 6, using a numeric pain scale of 1-10. She stated that she had some
throbbing pain where her staples were and then asked if it was time for some pain medication.
IK said that she did not sleep well the night before because she has been restless and she cannot
get comfortable because her head of bed has to be at 30 degrees in order for her to breathe. She
also stated that she was having pain all night where she had her knee replacement surgery. IK
has a #24 IV in her left hand with it heploked. The IV site was without redness, swelling, or
drainage. Her morning laboratory work can be found in Table 2.
Respiratory/Cardiovascular assessment
IK had even and unlabored respirations. Her lungs were diminished bilaterally
with wheezing. She did have a productive cough present with yellow/clear sputum. Her skin
turgor was good, she had pink nail beds, and the capillary refill in her extremities was under 3
seconds. She had strong radial pulses bilaterally but had weak pedal pulses bilaterally. IK had
plus 1 edema in both lower extremities. IK did not have any jugular vein distention. She had a
strong carotid pulse present bilaterally. She had a strong, even apical pulse, which had a rate of
90 beats per minute.
GERONTOLOGY PROCESS PAPER
13
Abdominal assessment
IK had hypoactive bowel sounds in all four quadrants. Her abdomen was distended but
not tender to the touch. She stated that she was not nauseous. She was continent of bowel and
bladder and was able to walk into the bathroom with a walker. She reported having no problems
with urinating. IK said that she has always had issues with constipation. Her last bowel
movement occurred on the morning of March 5, 2012 after the nurse gave her a laxative and a
suppository. Before that her last bowel movement was before her surgery on March 1, 2012.
Skin assessment
IK’s skin was pink, warm, and dry to the touch. She had good skin turgor, with no
tenting present. IK had moderate amount serosanguineous drainage coming out of her right knee
from the surgery. The left knee was swollen and had some erythema around the staples but was
dry and intact. The rest of her skin looked intact without bruising and markings. IK’s oral
mucosa was pink and moist. She had all of her own teeth present. Her throat was pink and
moist, with tonsils present. She had no drainage present. She had a Braden Scale score of 20/23.
IK’s hair was thick and appeared appropriate for her health and age. Her nails showed
thickening and slight yellowing bilaterally on both her fingers and toes.
Neurological Assessment.
IK was alert and oriented to person, place, and time (A&O x 3). Her level of
consciousness was alert. On the Glasgow Coma Scale, IK scored a 15/15. Her clarity of speech
was clear, and she was easy to communicate with. IK used glasses to assist her vision, but did
not require assistive devices for hearing. IK had a moderate bilateral grip in her hands, and is a
one assist with her walker. The nurse said that IK had a bed alarm on the count of her being a
GERONTOLOGY PROCESS PAPER
14
fall risk so anytime she wanted to get up and walk around someone had to accompany her. IK
also had PERRLA with both eyes.
Diet and activity.
MK had an order for up as tolerated as long as she had someone with her at all times
while walking around. On the Katz Index of Independence in Activities of Daily Living, IK
scored a 6 out of 6. She could perform all of her bath and needed minimal assistance with the
rest of her activities of daily living. From the time of her admission, IK had been on a cardiac
diet with boost supplement. She ate 100 percent of her dinner and was able to drink 360ml. The
only thing IK needed assistance on was making sure that her lids were taken off her drinks. She
also needed some assistance with ordering her meals for the day.
Assessment notes
While performing the assessment of IK her daughter was in the room as well. As I was
observing the interaction between mother and daughter I noticed that her daughter tends to make
IK’s anxiety level increase. Her daughter kept interrupting IK while she was trying to speak to
me. Then the daughter kept touching IK or trying to hold her hand and IK would get so angry
that she would yell at her daughter. The daughter’s cell phone seemed to be going off a lot and
she would answer it and start talking about IK’s diagnosis and treatment options. IK clearly told
the daughter a couple of times that she did not want her telling everyone why she was in the
hospital. After her daughter left the room to go get something to eat IK was relieved that she
could have some relaxation without her around. This was the perfect time to ask IK questions
from the Geriatric Depression Scale without her daughter around. IK scored a 6 on the scale
meaning that she is suggestive of depression. She just said that she has just been lonely without
GERONTOLOGY PROCESS PAPER
15
her husband here anymore and both of her daughters live out of state. I asked IK if she has
mentioned this to her daughters but she said that she does not want to burden them because they
have enough going on with their own families. IK then got quiet because her daughter came
back in the room.
When the daughter came back into the room it was the perfect time for some patient
teaching. The very first thing that was stressed was the importance of good handwashing. As
you touch people, surfaces and objects throughout the day, you accumulate germs on your hands.
In turn, you can infect yourself with these germs by touching your eyes, nose or mouth.
Although it's impossible to keep your hands germ-free, washing your hands frequently can help
limit the transfer of bacteria, viruses and other microbes. Always wash your hands before:
Preparing food or eating, treating wounds, giving medicine, or caring for a sick or injured
person, inserting or removing contact lenses Always wash your hands after: Preparing food,
especially raw meat or poultry, using the toilet or changing a diaper, touching an animal or
animal toys, leashes, or waste, blowing your nose, coughing or sneezing into your hands, treating
wounds or caring for a sick or injured person, handling garbage, household or garden chemicals,
or anything that could be contaminated — such as a cleaning cloth or soiled shoes (Mayo Clinic
Staff, 2011). In addition, wash your hands whenever they look dirty. It's generally best to wash
your hands with soap and water. Follow these simple steps: Wet your hands with running water.
Apply liquid, bar or powder soap. Lather well. Rub your hands vigorously for at least 20
seconds. Remember to scrub all surfaces, including the backs of your hands, wrists, between
your fingers and under your fingernails. Rinse well. Dry your hands with a clean or disposable
towel or air dryer. If possible, use your towel to turn off the faucet. Keep in mind that
antibacterial soap is no more effective at killing germs than is regular soap. Using antibacterial
GERONTOLOGY PROCESS PAPER
16
soap may even lead to the development of bacteria that are resistant to the product's
antimicrobial agents — making it harder to kill these germs in the future (Mayo Clinic Staff,
2011).
We also spoke of the importance of maintaining a heart healthy diet. A cardiac diet, as
the name suggests, is often prescribed for patients who have a history of heart related problems /
diseases. The cardiac diet is a healthy eating plan prepared to counter diseases such as high blood
pressure, obesity, heart attack and so on. Even if a person does not suffer from a heart condition
it is advisable to follow this diet as a preventive measure.
Table 1
Two types of fat that can be beneficial for the body are polyunsaturated fats and
monounsaturated fats. Polyunsaturated fats are found in foods such as:




leafy green vegetables
nuts
seeds
fish
Monounsaturated fats are said to decrease the levels of LDL or ‘bad’ cholesterol in the body.
They are found in foods such as:




milk products
avocado
olives
nuts
Unhealthy Fats:
One should avoid the consumption of trans fat and saturated fats. Trans fat increase the level of
bad cholesterol in the body. They are often found in:


packaged food items that are fried
in some of the foods sold in fast food restaurants
Although they help to increase the shelf life of a product they are very harmful for the body.
Saturated fats are found in foods such as:
GERONTOLOGY PROCESS PAPER




17
cream
cheese
butter
coconut oil
Consumption of Foods Rich in Fibre Content
Fibre rich food are an excellent source to reduce the levels of LDL (low-density lipoprotein) and
increase the levels of HDL (high-density lipoprotein) in our body. They also help in improving
digestion and preventing constipation. Foods that are rich in fibre include:





fresh fruits and vegetables (such as cabbage, carrots, broccoli, cauliflower)
legumes (soybeans, peas)
prunes
nuts and seeds
whole grains
Other Factors to Keep in Mind for an Effective Cardiac Diet Plan








Apart from the above mentioned factors, the following steps should also be implemented
to make your cardiac diet a successful and fruitful plan.
reduction of sodium intake
eating plenty of fresh fruits and vegetables
non-vegetarians are advised to take fish
reduction of the consumption of foods that are high in animal fats
elimination of caffeine consumption
avoiding consumption of foods that contain trans fat (trans fat or unsaturated fats increase
the level of LDL (low-density lipoprotein) or bad cholesterol and decrease the level of
HDL (high-density lipoprotein) or good cholesterol)
including foods that contain plant stanols (these increase the level of HDL and decrease
the level of LDL)
(Mayo Clinic Staff, 2011)
GERONTOLOGY PROCESS PAPER
18
Gordon’s Function Assessment
AREA OF HEALTH
SUBJECTIVE
DATA
OBJECTIVE
DATA
INDIRECT
DATA
*Identify source
of indirect data
HEALTH/PERCEPT
ION
HEALTH
MANAGEMENT
General Survey,
perceived health
& well-being, selfmanagement
strategies, utilization
of
preventative health
behaviors
and/or services.
IK stated that
she was feeling
okay today
besides some
pain in the
knees.
IK stated that
sometimes she
has some
problems
breathing.
IK requested to
have a breathing
treatment after
dinner.
Vital Signs:
Respirations 18
and unlabored,
pulse 93, temp
98.8°F, pulse
ox 95% on 2L
of oxygen via
nasal cannula,
BP 131/98.
Patient is
groomed and is
wearing a
hospital gown
with pajama
pants.
Patient does
participate in
most activities
of self-care.
IK is a little
down when by
herself in the
room, but when
staff or family
comes in to see
her she tends to
perk up a little
bit.
Patient spends
most of her
time lying in
bed watching
television or
playing cards
on her bedside
table.
Patient has orders
for use of
incentive
spirometer every
2 hours (chart).
Patient being
treated for current
symptoms of
COPD and
rheumatoid
arthritis (chart –
physician notes).
Patient has orders
for Leflunomide
daily and
Cefpodoxime
twice daily.
(chart).
Patient received
2-step Tb
screening once
admitted to the
hospital (chart).
Patient has been
vaccinated for the
following
diseases: polio,
Hepatitis B,
pneumonia,
influenza,
tetanus, and
MMR (chart).
INTERPRETAT
ION
(effective
patterns or
barriers/potenti
al barriers)
Patient feels like
she has nowhere
else to go, which
add to her
feelings of
depression and
anxiety.
She is trying to
keep her spirits
up, but she feels
abandoned due to
family being out
of state and
unable to provide
care.
Patient tries to
keep herself
occupied most of
the time with
television and
playing cards.
GERONTOLOGY PROCESS PAPER
NUTRITIONAL/
METABOLIC
Patterns of food and
fluid consumption,
Weight, skin turgor.
(Skin, Hair, Nails;
Head & Neck;
Mouth, Nose, Sinus;
swallowing, Ht., Wt)
ELIMINATION
Patterns of excretory
function &
Elimination of waste;
relevant labs,
Medications,
impacting, etc.
(Abdominal - bowel
and bladder)
19
Patient states
that she will eat
between 50-100
percent of her
meals,
depending on
what is offered.
Patient states
that she drinks
all liquids
offered during
meal times and
will drink her
boost
supplement that
is offered to her.
During shift pt.
ate 100% of
dinner.
Skin turgor
was less than
three seconds,
and no tenting
present.
Skin was dry
and warm with
good color.
Oral cavity was
moist and pink.
IK has all teeth
with no
dentures.
IK is 55.4
kilograms tall,
193 lbs.
IK can perform
own self care.
Cardiac diet with
thin liquids
(chart)
120 c.c. Boost
Supplement TID.
(chart)
IK never refuses
her boost
supplement
(nurse).
Patient states “I
normally did not
have any
problems
urinating but
since I got my
knees done I
have noticed
sometimes I will
leak if I wait too
long to go.”
Patient states “I
have always had
some problems
with
constipation but
if I take a
laxative it works
every time.”
Assessment
revealed
yellow, clear
urine.
Abdomen soft
symmetrical
and nondistended.
Bowel sounds
present in all
four quadrants.
Pt. denies pain
with
palpitation.
Patient is
administered
Lactulose 30ml
daily to help
with
constipation.
Patient is given
Patient had a
large bowel
movement on
March 5, 2012
(chart).
Perineal care is to
be done by
patient at least
twice a day
(chart-nurses
note).
Patient should be
taking the boost
supplement daily
as ordered in
order to have the
increased protein
to assist with
healing of knee
replacements and
to keep her
strength up.
Based on the
mucus production
that the patient is
dealing with, she
may benefit from
increasing her
fluid intake to
keep the
secretions easy to
move.
Due to patient not
moving around a
whole lot, normal
elimination
patterns are not
exhibited.
Based on the
constipation
problems the
patient could
increase fluids to
help get her
bowels working a
little bit better.
GERONTOLOGY PROCESS PAPER
20
18mcg daily of
Tiotropium
bromide which
can cause
constipation.
Patient is given
2mg morphine
sulfate as
needed every
two hours.
Patient is given
100mg
Atenolol which
can cause
constipation.
Patient is given
20mg
Furosemide
daily.
Patient is given
0.5mg Ativan
every six hours
when needed.
Patient is given
4mg of Zofran
every six hours
as needed.
Patient is given
Leflunomide
20mg daily
which can
cause a UTI.
Patient is given
30mg
Enoxaparin
every twelve
hours.
Patient is given
Cefpodoxime
proxetil 200mg
BID which can
cause diarrhea.
GERONTOLOGY PROCESS PAPER
ACTIVITY/EXERCI
SE
Patterns of exercise &
daily living,
self-care activities
include major
body systems
involved.
(Thoracic & Lung;
Cardiac;
Peripheral vascular;
Musculoskeletal,
vital signs)
IK stated that
she is having
some problems
breathing.
IK requested a
breathing
treatment after
she ate her
dinner.
IK states “I can
do my own care
but I still need
some help
getting my pants
started because
of my knee
surgery.”
IK states “I am
moving around
so much better
than I was a few
days ago”
IK states “Most
of the time I like
to just stay in my
room and watch
television or
play cards
because I am so
tired after
therapy.”
21
Heart sounds
were regular.
Lung sounds
included
wheezing
bilaterally.
Patient was
breathing at 18
respirations per
minute.
The sputum
that was
collected was
white/yellow in
color.
Katz ADL
score was 6 out
of 6.
Lower
extremities
have minimal
edema present.
Patient had a
Braden score
of 20/23.
Patient is a fall
risk because of
her bilateral
knee surgery
and some of
the medications
that she is
currently
taking.
Patient is given
Enoxaparin
30mg every
twelve hours.
Patient is given
2mg of
Morphine
sulfate every
two hours
when needed.
Patient is up as
tolerated (chart).
Patient requires
someone to be
with her when
she is up walking
around (chart).
Patient also has a
bed alarm to
prevent her from
getting up
without help
(chart).
Patient is ordered
up to the chair for
all meals daily
(chart).
Patient has 2
bedrails up to
help her turn in
bed (chart-nurses
notes).
IK has physical
and occupational
therapy ordered
three times a day
(physician order).
IK has history of
myocardial
infarction which
occurred in the
spring of
1998(chart).
Patient’s Braden
score indicates
that she is in
good shape from
having any skin
breakdown.
Patient can
perform most of
her activities of
daily living.
IK needs to get
up moving
around in the
evening to keep
up with therapy
so the bilateral
knee surgery was
not a waste of
time.
GERONTOLOGY PROCESS PAPER
22
Patient is given
0.5mg Ativan
every six hours
as needed.
Patient is given
Zofran 4mg
every six hours
when needed
Patient is given
Furosemide
20mg daily
before meals.
Patient is given
30ml of
Lactulose daily
when needed.
SEXUALITY/
REPRODUCTION
Satisfaction with
present level of
Interaction with sexual
partners
(Breast; Testes;
AbdominalGenitourinaryreproductive)
Patient stated “I
have not had a
sexual
relationship in a
very long time.”
Patient stated “It
would be nice to
have a
companion to
just hang out
with so I am not
so lonely.”
Patient said that
there was
nothing else to
talk about in this
area of her
health.
Patient
changed the
subject and
would discuss
no further.
Found no
information
regarding
sexuality from
chart.
This topic
seemed to bring
IK’s spirits down
somewhat.
She started to
make a face,
indicating that
this was not a
pleasant subject
for her.
SLEEP/REST
Patterns of sleep, rest,
relaxation,
fatigue
(Appearance,
behavior)
Pt states “I sleep
for almost 8
hours a night.”
Patient states “I
normally do not
have any
problems
sleeping. That
was one thing I
During the
shift the patient
seemed fatigue
and wanted to
just sleep.
Patient did nap
for an hour.
Patient is given
2mg Morphine
Morphine,
Ativan, and
Zofran will lead
to drowsiness
(chart).
IK seems to have
just enough
energy to make it
through her
activities of daily
living and
therapy.
GERONTOLOGY PROCESS PAPER
23
was always good sulfate every
at.”
two hours
when needed.
Patient is given
0.5mg Ativan
every six hours
as needed.
Patient is given
4mg Zofran
every six hours
when needed.
COGNITIVE/
PERCEPTUAL
Patterns of thinking &
ways of
Perceiving
environment,
orientation
Mentation, neuron
status, glasses,
Hearing aids, etc.
IK was able to
describe herself,
surroundings,
and situation
very explicitly.
IK states “I
know how long I
have been
here…way too
long.”
A and O x4
person place
time situation
Pupils equal
and reactive.
Does not use
hearing aid.
Patient wears
glasses full
time to correct
vision
deficiencies.
Patient is given
2mg morphine
every two
hours daily as
needed.
Patient is given
Ativan 0.5mg
every six hours
when needed.
Nurse and
physician notes
indicate patient
has regularly
been alert and
oriented (chart).
IK does not
appear to have
any cognitive
impairment at
this time.
ROLE/RELATIONS
HIP
Patterns of
engagement with
others,
Ability to form &
maintain meaningful
Relationships,
assumed roles;
Family
communication,
Patient states “I
have two
wonderful
daughters with
five
grandchildren
and two greatgrandchildren.”
Patient stated
“Both of my
daughters
Patient had
some photos of
her
grandchildren
and greatgrandchildren.
The patient had
her one
daughter in the
room visiting
her.
Nothing indicated
on chart about
relationships with
family or within
community.
IK appears to
have a good
relationship with
both of her
daughters. She
was just upset
that they both
live out of state.
GERONTOLOGY PROCESS PAPER
response,
Visitation, occupation,
community
involvement
currently live out
of state with
their families.”
Patient states
that she does not
see her family
very much.
Patient states
“My husband
passes away last
year and that
was the last of
my family that
live around
here.”
Patient states: I
use to work a
long time ago
and I miss the
interaction. I
was thinking
about
volunteering
when I got better
just to have
something to do
with my free
time.”
SELFPERCEPTION/
SELF-CONCEPT
Patterns of viewing &
valuing
Self; body image &
psychological
state
IK states that
when she is at
home, she has
her own car to
be able to get
from place to
place.
She stated “I use
to go out all the
time to just get
out of the house
but in the last
couple of
months my
COPD started
acting up again
and I have not
24
IK asked
questions about
her pulse,
blood pressure
and
temperature
during
assessment.
IK provided
information
about past
employment
history.
Patient is given
0.5mg Ativan
every six hours
Patient is
documented to
have depression
and anxiety
(chart).
Patient is a Full
Code (chart).
IK is not use to
depending on
other people.
Her self-image is
at risk for being
disturbed as she
is relying on
strangers to
provide care due
to her family’s
inability to do so.
Her self-concept
seems to be very
affected on the
fact that she will
GERONTOLOGY PROCESS PAPER
been out since.”
25
when needed.
IK stated “The
Patient appears
doctor
very tired.
mentioned I
might have to go
into a skilled
nursing facility
to get some
more rehab. I am
not happy with
that at all.
People who go
in there do not
come out.”
IK stated “I
know I should
start planning
my funeral and
getting it paid
off but I am
scared to die.”
Patient states
that her level of
anxiety is a 6 on
a scale of 1-10.
Patient feels that
her level of
control in her
current situation
is a 3 on a scale
of 1 to 10.
Patient states “I
feel like I do not
have any control
over my life
anymore.
Getting old
stinks.”
probably have to
go in a skilled
nursing facility.
GERONTOLOGY PROCESS PAPER
26
COPING/STRESS
TOLERANCE
Stress tolerance,
behaviors, patterns
of coping with
stressful events &
level of effectiveness,
depression,
anxiety.
Patient states
that she would
love to go home
and have her
daughters help
take care of her
but she knows
that it is not an
option.
Patient states “I
thought about
having the Full
Code changed to
a DNR but I just
am not sure
about it yet.”
Patient states
that she manages
stress and
anxiety with the
use of
medication.
On the
Geriatric
Depression
Scale, patient
score of 6
indicated
depression.
IK is
prescribed
0.5mg of
Ativan every
six hours as
needed.
Patient is ordered
to have Ativan
every six hours as
needed (chart).
Patient is clearly
depressed by the
passing of her
husband and the
fact that her
daughters live out
of state. She
feels as if she has
no one here to
help take care of
her.
Patient also has
some anxiety
about the idea of
a skilled nursing
facility.
VALUE/BELIEF
Patterns of belief,
values,
Perception of meaning
of life that
guide choices or
decision; includes
but is not limited to
religious beliefs
IK states that she
is Catholic.
Patient states
“Ever since they
closed down my
church I have
been looking for
a new one to go
to but have not
got around to it
yet.”
IK’s daughter
brought her a
cross to put in
her room.
IK has a bible
in her room.
IK is a Full
Code.
Patient is of
Catholic faith
(chart).
IK seems to have
a Catholic based
belief, although
she does not
appear to be
involved in many
religious
traditions since
she has gotten
sick.
IK is not sure
how she feels
about taking extra
measures in case
of a serious
health incident.
GERONTOLOGY PROCESS PAPER
27
Laboratory Information
Table 2
Tests
Hemoglobin
Normal Values
Patient Results
Analysis
12-16 g/dL
9.9
Low because patient could be
anemic and also she has fluid
retention which causes
hemodilution.
Hematocrit
36%-48%
34.0%
Low because patient could be
anemic and also she has fluid
retention which causes
hemodilution.
RBC
4-5 million/mm3
3.40
Low because patient could be
anemic and possible fluid overload.
WBC
5000-10,000 /mm3
9.2
WNL
Platelets
150,000-450,000 /mm3
196
WNL
Sodium
135-145
144
WNL
Potassium
3.5-5.0
4.6
WNL
95-105 mEq/L
100
WNL
CO2
21-32
28
WNL
Glucose
70-100
169
Increased because of several
different medications the patient is
on, stress, or due to illness – or a
combination of all three
5-20 mg/dL
12
WNL
0.6-1.3 mg/dL
0.80
WNL
10:1 – 20:1
15
WNL
Chloride
BUN
Creatinine
BUN/Creatinine


Normal Values from:
Professional Guide to Diagnostic Tests.
Nurse’s manual of laboratory and diagnostic tests (4th ed).
GERONTOLOGY PROCESS PAPER
28
Medications
Table 3
Medication
Classification
(Generic and
Trade)
&
Generic:
Tiotropium
bromide
Trade: Spiriva
Why is your
patient taking
this drug?
Dosage/
Route
My patient is
taking this
medication for
long-term
maintenance
treatment of
bronchospasm due
to COPD.
Inhaln:
18mcg once
daily
My patient is
taking this
medication for the
treatment of her
COPD.
Inhaln:
2.5mg 4
times a day.
Side Effects
Purpose
Therapeutic
Classification:
bronchodilators
Pharmacologic:
Anticholinergic
Purpose: Acts as
anticholinergic by
selectively and reversibly
inhibiting M3 receptors in
smooth muscle of airways.







Glaucoma
Paradoxical
bronchospasm
Tachycardia
Dry mouth
Constipation
Urinary retention
Hypersensitivity
reactions including
angioedema
Therapeutic Effects:
Decreased incidence and
severity of bronchospasm.
Generic:
Albuterol
Trade: Proair
HFA
Therapeutic
Classification:
Bronchodilators
Pharmacologic:
Adrenergics
Purpose: Used as a
bronchodilator to control
and prevent reversible
airway obstruction caused
by asthma or COPD.
Binds to beta 2 adrenergic
receptors in airway
smooth muscle.













Nervousness
Restlessness
Tremor
Headache
Insomnia
Paradoxical
bronchospasm
Chest pain
Palpitations
Arrhythmias
Hypertension
Nausea
Vomiting
Hyperglycemia
GERONTOLOGY PROCESS PAPER
29
Therapeutic Effects:
Bronchodilation
Generic:
Atenolol
Therapeutic
Classification:
Antianginals,
antihypertensives
Trade:
Tenormin
Pharmacologic: Beta
blocker
My patient is
taking this
medication for a
history of an MI
and hypertension.
PO: 100mg
twice a day.
Purpose: Management of
hypertension.
Management of angina
pectoris. Prevention of
MI.
Therapeutic Effects:
Decreased blood pressure
and heart rate. Decreased
frequency of attacks of
angina pectoris.
Generic:
Furosemide
Trade: Lasix
Therapeutic
Classification: Diuretics
Pharmacologic: Loop
diuretics
Purpose: Edema due to
heart failure, hepatic
impairment or renal
disease. Hypertension.
Inhibits the reabsorption
of sodium and chloride
from the loop of Henle
My patient is
PO: 20mg
taking this for a
daily ac.
number of reasons.
She has
hypertension,
pleural effusion,
COPD, and CHF.

Hypokalemia









Fatigue
Weakness
Anxiety
Depression
Dizziness
Drowsiness
Insomnia
Memory loss
Mental status
change
Nervousness
Bradycardia
CHF
Pulmonary edema
Hypotension
Vasoconstriction
Constipation
Nausea
Vomiting
Hyperglycemia
Hypoglycemia
Erectile dysfunction
Aplastic anemia
Agranulocytosis
Dehydration
Hypokalemia
Hypochloremia
Hypomagnesemia
Hyponatremia
Hypovolemia
Metabolic alkalosis
Hypocalcemia
Blurred vision
Dizziness
























GERONTOLOGY PROCESS PAPER
30







and distal renal tubule.
Therapeutic Effects:
Diuresis and subsequent
mobilization of excess
fluid (edema, pleural
effusions). Decreased
blood pressure.
Generic:
Prednisone
Trade:
Sterapred
Purpose: Used
systemically and locally
in a wide variety of
chronic diseases
including: inflammatory,
allergic, hematologic,
neoplastic, autoimmune
disorders. In
pharmacologic doses,
suppresses inflammation
and the normal immune
response.
My patient is
taking this
medication for
the treatment of
COPD.
PO: 10mg
daily with a
meal.



















Depression
Euphoria
Hypertension
Peptic Ulceration
Anorexia
Nausea
Acne
Decease wound healing
Eccymoses
Fragility
Hirsumtism
Petechiae
Adrenal suppression
Fluid retention
Thromboembolism
Muscle wasting
Osteoporosis
Cushingoid appearance
Hypokalemia
My patient is
taking this
medication for
the infection in
her lungs.
PO: 200mg
twice daily.



Seizures
Headache
Pseudomembranous
colitis
Diarrhea
Rash
Bleeding
Abdominal pain
Nausea
Vomiting
Uticaria
Hemolytic anemia
Therapeutic Effects:
Suppression of
inflammation and
modification of the
normal immune response.
Generic:
Cefpodoxime
proxetil
Trade: Vantin
Therapeutic
Classification:
Anti-infectives
Pharmacologic: Third
generation cephalosporin.
Purpose: Treatment of
different infections
caused by susceptible
organisms. Binds to the
bacterial cell wall
membrane, causing cell
death.
Therapeutic Effects:
Headache
Vertigo
Hearing loss
Tinnitus
Hypotension
Hyperglycemia
Dry mouth








GERONTOLOGY PROCESS PAPER
31
Bactericidal action
against susceptible
bacteria.
Generic:
Enoxaparin
Trade:
Lovenox
Therapeutic
Classification:
Anticoagulants
Pharmacologic
Classification:
Antithrombotics, low
molecular weight
heparins
Generic:
Leflunomide
Trade: Arava
Pharmacologic
Classification: Immune
Response Modifiers
Purpose: Treatment of
Rheumatoid arthritis
Therapeutic Effects:
Decreased pain and
inflammation, slowed
structural progression
and improved physical
function.
Superinfection
My patient is
taking this
medication to
prevent a clot
from forming
after her bilateral
knee surgery.
SC: 30mg
every 12hrs.












Bleeding
Anemia
Dizziness
Headache
Insomnia
Edema
Constipation
Urinary retention
Ecchymoses
Pruritus
Rash
Hyperkalemia
My patient is
taking this
medication for
her Rheumatoid
arthritis.
PO: 20mg
daily













Headache
Interstitial lung disease
Hepatotoxicity
Diarrhea
Nausea
Alopecia
Rash
Dizziness
Weakness
Cough
Pneumonia
Chest pain
Hypertension
Purpose: Prevention of
venous
thromboembolism or
pulmonary embolism in
surgical or medical
patients.
Therapeutic Effects:
Prevention of thrombus
formation.
Therapeutic
classification:
Antirheumatics

GERONTOLOGY PROCESS PAPER
Generic:
Lactulose
32
My patient is
taking this
medication
because she has a
history of
constipation.
PO: 30ml
daily prn
Trade: Cholac,
Constilac,
Constulose,
Enulose,
Generlac,
Kristalose
Therapeutic
Classification: laxatives
Pharmacologic:
Osmotics
Purpose: Treatment of
chronic constipation.
Therapeutic Effects:
Relief of constipation.
Decreased blood
ammonia levels with
improved mental status in
PSE.
Generic:
Morphine
sulfate
Therapeutic
Classification: Opioid
analgesics
My patient is
taking this
medication for
pain.
IV: 2mg
every 2
hours prn.
Trade:
Astramorph,
Avinza,
DepoDur,
Duramorph
Pharmacologic: Opioid
agonists
My patient is
taking this
medication
because she has
high anxiety.
IV Injection:
0.5mg every
6 hours prn.
Purpose: Severe pain,
pulmonary edema, pain
associated with MI.
Therapeutic Effects:
Decrease in severity of
pain.
Generic:
Lorazepam
Trade: Ativan
Therapeutic
Classification: Analgesic
adjuncts, antianxiety
agents,
sedative/hypnotics
Pharmacologic:
Benzodiazepines
Purpose: Used for
anxiety disorder,
preoperative sedation,






Belching
Cramps
Distention
Flatulence
Diarrhea
Hyperglycemia












Confusion
Sedation
Respiratory depression
Hypotension
Constipation
Dizziness
Bradycardia
Urinary retention
Flushing
Itching
Euphoria
Diplopia











Dizziness
Drowsiness
Lethargy
Apnea
Cardiac arrest
Headache
Ataxia
Slurred speech
Blurred vision
Respiratory depression
Bradycardia
GERONTOLOGY PROCESS PAPER
33
decrease preoperative
anxiety and provides
amnesia. Depresses the
CNS, probably by
potentiating GABA, an
inhibitory
neurotransmitter.






Hypotension
Constipation
Nausea
Vomiting
Rash
Confusion










Headache
Constipation
Diarrhea
Dizziness
Drowsiness
Fatigue
Weakness
Abdominal pain
Dry mouth
Increased liver
enzymes
Extrapyramidal
reactions
Therapeutic Effects:
Sedation, decreased
anxiety, decreased
seizures.
Generic:
Ondansetron
Therapeutic
Classification:
Antiemetics
Trade: Zofran
Pharmacologic: Five ht3
antagonists
My patient is
taking this
medication to
help with the
nausea that she
has been having.
Purpose: Prevention of
nausea and vomiting.
Therapeutic Effects:
Decreased incidence and
severity of nausea and
vomiting following
chemotherapy or surgery.
IV: 4mg
every 6
hours prn.

Medication references used:

Davis’ Drug Guide (12th ed).
Analysis
Nursing Diagnosis #1
The primary nursing diagnosis that I chose for IK was Risk for Infection related to having
staples in bilateral knees, the drainage that was coming out of her left knee from the surgery and
she was not always letting the nurses change the dressings because she said it hurt too bad, also
the fact that she has COPD and CHF, she has been on long term Prednisone which can cause the
skin to become paper like and tear open easily. Also a side effect from one of the medications is
GERONTOLOGY PROCESS PAPER
34
a urinary tract infection. Also IK is going to have to go to a skilled nursing care facility where
she is going to be at higher risk for infection from the other residents.
Nursing Diagnosis #2
The secondary nursing diagnosis that I chose for IK was Impaired Skin Integrity related
to immobility after therapy, and use of diuretics as evidenced by plus one edema on lower
extremities, CHF, and COPD. IK has orders to be up in her chair after therapy for a few hours
but all she wants to do is lay down. IK also has orders to be up for all meals but for the most part
she refuses that as well. She also has a bed alarm which prohibits her to move freely around her
room without anybody. IK also has drainage still coming out of her left knee from her surgery
but sometimes will not let you change the dressing because she said her knees hurt her.
Nursing Diagnosis #3
The third nursing diagnosis that I chose for IK was Social Isolation related to physical
isolation from family as evidenced by expressed feelings of isolation and loneliness which can
lead to more cardiovascular problems (Sherman, 2012), and absence of family members. IK
repeatedly discussed her feelings of loneliness and isolation due to her husband passing away
and her family living out of state. She stated that she feels so lonely and that she has no one
anymore. Also she is not happy about the fact that she is going to have to go to a skilled nursing
facility to finish her therapy. She stated that she is not going to talk to anyone at that nursing
home because she should not be there. She also stated that she misses working for the social
interaction that it provided her. She seems to have some symptoms of depression with
everything that has happened to her in the past year.
GERONTOLOGY PROCESS PAPER
35
Nursing Diagnoses, Plans, Interventions, and Evaluation
Table 4
Primary Nursing
Diagnosis:
Risk for Infection related to staples from bilateral knee surgery,
drainage from left knee site, COPD, CHF, medications (CarpenitoMoyet, 2010).
Patient Goal:
Patient will indicate an understanding of risk factors for developing
infection and preventative measures that she can engage in by the end
of shift.
Interventions:
1. Explain the importance of adequate nutrition. Work with IK to
develop intake goals for snacks and meals. Encourage fluids to 2500
mL/day (Doneges, Moorhouse, and Murr, 2010).
Rationale: Helps to improve general resistance to disease and
reduces risk of infection from static secretions (Donegas et al., 2010).
2. Observe color, odor, and characteristics of sputum. (Doneges et al.,
2010).
Rationale: Yellow or green, purulent odorous sputum is indicative of
infection. Thick, tenacious sputum potentially indicates dehydration
(Donegas et al., 2010).
3. Provide meticulous, clean, or aseptic care; maintain good
handwashing techniques (Donegas et al., 2010).
Rationale: First line of defense against nosocomial infections
(Fraczyk et al., 2011).
4. Encourage deep breathing and use of incentive spirometer (Donegas
et al., 2010).
Rationale: Enhances mobilization and clearing of pulmonary
secretions to reduce risk of pneumonia and atelectasis (Donegas et al.,
2010).
Evaluation:
Short term goal met. IK verbalized an understanding of basic infection
precautions and prevention. She also verbalized an understanding of
the importance of following her diet in the hospital, and stated that she
would increase her fluid intake when she was back in room from
GERONTOLOGY PROCESS PAPER
36
therapy.
Table 5
Secondary Nursing
Diagnosis:
Impaired Tissue Integrity related to altered circulation, effects of
medication, accumulation of drainage, altered metabolic state.
(Carpetino-Moyet, 2010).
Patient Goal:
Patient will demonstrate behaviors or techniques to promote healing
and prevent complications within 30 days.
Interventions:
1. Maintain strict skin hygiene, using mild, non detergent soap, drying
gently and thoroughly, and lubricating with lotion or emollient
(Donegas et al., 2010).
Rationale: A daily bath may create dry skin problems. Use of
lubricants keep skin soft and pliable, and help to keep susceptible skin
from breaking down (Donegas et al., 2010).
2. Observe for decubitus ulcer development and treat immediately
according to protocol (Donegas et al, 2010).
Rationale: Timely intervention may prevent extensive damage
(Donegas et al., 2010).
3. Assist with topical applications, such as hydrogel dressings, skin
barrier dressing, collagenase therapy, absorbable gelatin sponges, and
aerosol sprays (Donegas et al., 2010).
Rationale: Although there are differing opinions about the use of
these agents, individual or combination use may enhance healing
(Donegas et al., 2010).
4. Reinforce initial dressing or change, as indicated. Use strict aseptic
techniques.
Rationale: Protects wound from mechanical injury and
contamination. Prevents accumulation of fluids that may cause
excoriation (Donegas et al., 2010).
Evaluation:
Unable to assess due to not seeing patient again. In order to help her
reach her goal of healing, I would educate her on the importance of
following the doctor’s orders to promote healing. I would work with
her to schedule the interventions at a time that she would be
comfortable with.
GERONTOLOGY PROCESS PAPER
37
Table 6
Tertiary Nursing
Diagnosis:
Social Isolation related to physical isolation from family as evidenced
by expressed feelings of isolation and loneliness, and absence of family
members (Carpenito-Moyet, 2010).
Patient Goal:
Patient will participate in activities and programs at level of ability and
desire daily.
Interventions:
1. Ascertain client’s perception of situation (Donegas et al., 2010).
Rationale: Isolation may be partly self-imposed because client fears
rejection or reaction of others (Donegas et al., 2010)
2. Be alert to verbal and nonverbal cues including withdrawal,
statements of despair, and sense of aloneness. Ask client if thoughts of
suicide are being entertained. (Donegas et al., 2010).
Rationale: Indicators of despair and suicidal ideation are often
present. When these cues are acknowledged by the caregiver, client is
usually willing to talk about thoughts of suicide and sense of isolation
and hopelessness (Donegas et al., 2010).
3. Spend time talking to patient during and between care activities. Be
supportive, allowing for verbalization. Treat with dignity and regard
for client’s feelings (Donegas et al., 2010).
Rationale: Client may experience physical isolation as a result of
current medical status or location. Due to age, patient may experience
social isolation in his living situation (Donegas et al., 2010).
Evaluation:
Short term goal met. The patient participated in a card game with a
patient that was across the hall. She also communicated some worries
of hers to her daughter.
GERONTOLOGY PROCESS PAPER
38
Conclusion
At the conclusion of this shift, I felt that IK had done well throughout the day when I
cared for her. Her physical status did not change during the course of my shift. As for her spirits
and general mood, she seemed to have an increase in spirits during the time that I was giving
care to her. We developed a good rapport, and she was open to any education or suggestions that
I had for her. As the day progressed, she became more comfortable with me and opened up
about her highs and lows of the past couple of months, and eventually years. She was willing to
discuss things with me at the end of the shift that she had not been willing to discuss earlier
about her past medical history. She stated that she would work to improve her health in the ways
that we had discussed.
GERONTOLOGY PROCESS PAPER
39
References
Black, J. M. & Hawk, J. H. (2009). Medical surgical nursing: clinical management for positive
outcomes (8th ed.). Saint Louis, Missouri: Saunders Elsevier.
Carpenito-Moyet, L. J. (2010). Handbook of nursing diagnosis (13th ed.). Philadelphia,
Pennsylvania: Lippincott, Williams, & Wilkins.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing care plans: guidelines for
individualizing client care across the life span (8th ed.). Philadelphia, Pennsylvania: F. A.
Davis Co.
Hopfer, J., Vallerand, A., & Sanoski, V. (2010). Davis’s drug guide for nurses (12th ed.).
Philadelphia, Pennsylvania: F. A. Davis Co.
Mayo Clinic Staff. (2011, August 11). Hand-washing: Do's and don'ts. Retrieved from
http://www.mayoclinic.com/health/hand-washing/HQ00407.
Mayo Clinic Staff. (2011, August 2). Heart-healthy diet: 8 steps to prevent heart disease.
Retrieved from http://www.mayoclinic.com/health/heart-healthy-diet/NU00196.
Schilling, J. A., & Robinson, J. M. (2005). Professional guide to diagnostic tests. Philadelphia:
Lippincott Williams & Wilkins.
Sherman, A. J. (2012). Unbreak your heart. Natural Health, 42(2),
GERONTOLOGY PROCESS PAPER
40
Article
Title:
Unbreak YOUR heart. By: Sherman, Alexa Joy, Natural Health, 10679588, Feb2012,
Vol. 42, Issue 2
Database:
Alt HealthWatch
Unbreak YOUR heart
Contents
1. Heart hazard: Anger
2. Hearth hazard: Depression
3. Heart hazard: Loneliness
Listen Pause
Loading
American Accent
Medium Reading Speed
Download MP3
Help
Each of our healing soup recipes serves four: the perfect amount for sharing (or leftovers the next
day).
You probably know that heart diseases the leading killer of women and men in the United States
-- and how does that make you feel? Sad? Angry? Well, for the good of your heart, you might
want to turn that frown upside-down. Research increasingly suggests that our mental and
cardiovascular health are intrinsically linked. "We know that anger, depression and even
loneliness release stress hormones like adrenaline and Cortisol," says Mimi Guarneri, M.D.,
founder and medical director of the Scripps Center for Integrative Medicine in La Jolla, Calif.,
and author of The Heart Speaks: A Cardiologist Reveals the Secret Language of Healing
(Touchstone). "Those stress hormones raise blood pressure and cholesterol, constrict arteries and
cause arrhythmia (irregular heartbeat)."
Cortisol also contributes to abdominal obesity, as well as type II diabetes -- both welldocumented risk factors for heart disease -- Guarneri adds. Plus, emotions often lead us to make
choices that compromise our heart health (think: smoking, drinking, physical inactivity). On a
happier note, these things can be controlled. "Eighty percent of illness is related to lifestyle and
environment," says Guarneri. Translation: If you make smart choices -- like those that follow -you can dramatically alter both your outlook and your health. So put your mind to it, and let the
healing begin.
Heart hazard: Anger
GERONTOLOGY PROCESS PAPER
41
Recent research published in the journal Circulation found that healthy women who scored high
on tests of cynical hostility had higher rates of coronary heart disease (CHD) and mortality than
women who tested high for optimism. A study from Johns Hopkins University in Baltimore
found that medical students who became angry quickly when under stress were three times more
likely to develop premature heart disease and five times more likely than their calmer colleagues
to have an early heart attack. Sure, it's wise to let it out rather than bottle it up, but even better is
developing more resilient and less aggressive responses to stressful situations. So don't get mad - get even-keeled with this heart-healthy anger-management advice:
Calm down According to a long-term study of subjects with CHD, transcendental meditation
(TM), which involves allowing the mind to relax and, in essence, transcend thought, rather than
attempting to focus on something specific, was associated with a 47 percent reduction in
mortality, nonfatal myocardial infarctions (aka heart attacks) and strokes. "Other types of
meditation are good, too, but TM has the strongest evidence in the cardiology literature,"
Guarneri notes. If meditation doesn't jibe with you, take a spa day instead. A recent study
published in the Journal of Alternative and Complementary Medicine found that deep-tissue
massage reduced blood pressure levels by an average of 10.4 mm Hg and resting heart rate by
nearly 11 beats per minute.
Work it out Meditative exercises like yoga and tai chi achieve similar results to the
aforementioned relaxation practices, and in fact most types of physical activity can help your
head and your heart. Some research suggests outdoor exercise is particularly effective for
combating feelings of tension and anger.
Eat enough Deprivation makes you mad. A recent study published in the Journal of Consumer
Research found that people who ate apples for dietary reasons were more likely to watch movies
with themes of anger and revenge than individuals who ate chocolate. "Exerting self-control
makes people more likely to behave aggressively toward others, and people on diets are known
to be irritable and quick to anger," the authors said. So indulge occasionally, keeping your ticker
in mind. "Have a piece of dark chocolate -- it has emotional and heart-health benefits," says
Andrew Weil, M.D., founder and director of the Arizona Center for Integrative Medicine at the
University of Arizona in Tucson and author of Spontaneous Happiness (Little, Brown & Co.).
Also, make sure you don't skip meals, adds Tracy Stevens, M.D, a cardiologist at St. Luke's Mid
America Heart Institute in Kansas City, Mo., and spokeswoman for the American Heart
Association (AHA). When you get too hungry and your blood sugar drops, that can lead to stress
and anger, as well as making poor food choices -- which are frequently not good for your heart,
Stevens says. One thing you can cut out (or at least way back on): alcohol, which can contribute
to high blood pressure and aggressive behavior.
Hearth hazard: Depression
Sad but true: Cardiovascular disease (CVD) makes depressive symptoms worse, and vice versa.
Not only have studies found that depression is common following heart attacks and other
coronary events, but in one of many examples, researchers from Washington University School
of Medicine in St. Louis recently concluded that a history of major depression increases the risk
for heart disease more than genetics or environment. So clear is the connection that the latest
GERONTOLOGY PROCESS PAPER
42
guidelines from the AHA recommend depression screening as part of an overall evaluation for
CVD risk. Fortunately, many remedies that help ease depression can also boost heart health:
Score with supplements Vitamin D deficiencies have been linked to Alzheimer's disease,
depression and cognitive decline, as well as to heart disease -- but supplementation (600 to 4,000
IU daily for depression and 1,000 to 5,000 IU per day for the heart) can help considerably.
Studies show that a lack of omega-3 fatty acids has similar implications for the head and the
heart. "Omega-3 deficiency leads to weakened brain architecture and function and strongly
correlates with depression," says Weil. "It also increases inflammation and clotting tendency of
the blood, both of which increase the risk of heart disease." Weil recommends taking 2 to 4
grams a day of a product that provides both EPA and DHA, and looking for products that are
"molecularly distilled" or otherwise guaranteed to be free of toxins. (Many manufacturers -including Nordic Naturals, nordicnaturals.com -- offer combined omega-3 and vitamin D3
supplements.)
Feed your head Another way to combat both depression and heart disease is with an antiinflammatory diet, which places a particular emphasis on fresh fruits, vegetables, legumes and
healthy fats, plus smaller amounts of whole grains and limited foods from animal sources. "Steer
clear of meat and poultry as much as possible, which tend to be high in pro-inflammatory fats,
and avoid processed and fast foods and sugary drinks -- the fats and quick-digesting
carbohydrate in them are strongly pro-inflammatory," says Weil. (Get all the details -- including
an "anti-inflammatory diet pyramid" -- at drweil.com.)
Bust a move Countless studies have found that exercise alleviates symptoms of depression, and
its impact on heart health is undisputed as well. "As far as natural treatments for depression are
concerned, 30 minutes of aerobic exercise five times per week is one of the most effective, and
should yield results within a few weeks," notes Weil. That's about how much the AHA
recommends for heart health, too, (For more suggestions, see "The Heart-Smart Workout Chart,"
pg. 95.)
Heart hazard: Loneliness
The life expectancy for the lonely hearts' club is looking grim. One study of heart attack
survivors found that those who scored high on tests of social isolation and stress were four times
as likely to die during the three years after their attacks compared with those who had large
social networks and less stress. A recent Danish study also reported that people who live alone
are twice as likely to suffer from "serious heart disease" as those living with partners.
Meanwhile, a survey of more than 200 people in Chicago found that blood pressure was 30
points higher among lonely people than those who felt more connected to others. But there is
hope for the misanthropes:
Improve your partnership Recent research from the University of Rochester in New York found
that happily married people who underwent coronary bypass surgery were more than three times
as likely to be alive 15 years later compared with their unmarried counterparts. But according to
one University College London study, being unhappy with a significant other is a strong
predictor of coronary events. Most forms of psychotherapy can help. "Relationships break down
GERONTOLOGY PROCESS PAPER
43
for all kinds of reasons, including issues of self-esteem, guilt, shame and a lack of
communication," says Judith Orloff, M.D., assistant clinical professor of psychology at the
University of California, Los Angeles, and author of Emotional Freedom: Liberate Yourself from
Negative Emotions and Transform Your Life (Three Rivers Press). "Talking things through with
a professional -- individually or as a couple -- can help partners delve into the underlying issues
and work toward correcting them."
Get a pet A whole body of research suggests that companion animals are beneficial for both
emotional and physical health. One study of stockbrokers who were on angiotensin converting
enzyme inhibitor medication (used to treat hypertension) -- and all of whom had lived alone for
five years -- found that those who were given a cat or dog remained significantly more stable
during stressful situations than test subjects in the no-pet group. "If you have high blood
pressure, a pet is very good for helping you during times of stress, and pet ownership is
especially good for you if you have a limited support system," says study author Karen Allen,
Ph.D., professor of medicine at the University of Buffalo in New York.
Give a little bit The reasons for social isolation are often self-inflicted. "Some evidence even
suggests that susceptibility to heart attack correlates with how often people use the words 'I,' 'me'
and 'mine' in casual speech," notes Weil. On the flip side, a review of studies released by the
Corporation for National and Community Service found that people who volunteer have greater
longevity, higher functional ability, lower rates of depression and less incidence of heart disease.
The opportunities to help others are limitless; there's even a national support group for people
with heart disease, Mended Hearts (mendedhearts.org), which forges connections between heart
patients. "Helping others creates connections that bring you joy," says Guarneri. "When you do
something for someone else and you see that you've made a difference, you never forget that.
Your heart is truly full."
A growing body of research suggests a strong link between mental and heart health. Find out
which mind-sets are most harmful and how to manage them -- plus five types of exercise you
need now and one surprisingly deadly diet mistake.
A history of major depression can increase the risk for heart disease more than genetics or
environment -- so much so that the AHA recommends depression screening as part of the risk
assessment for cardiovascular disease.
The heart-smart workout chart Cardio isn't the only type of exercise your heart needs. "Most
activities help to lower overall blood pressure as well as stress, which will in turn reduce
inflammation and improve heart health," notes Andrew Wolf, M.Ed., an exercise physiologist
with Miraval Arizona Resort and Spa in Tucson, Ariz. So make aerobic activity your primary
focus, but liberally sprinkle in these activities as well.
Legend for Chart:
A - EXERCISE TYPE & WHY TO &heart; IT
B - TRAINING TIPS
A
B
GERONTOLOGY PROCESS PAPER
44
Cardio/aerobics Helps to maintain a healthy weight, strengthens the
heart and lungs, boosts the body's ability to use oxygen, and can help
lower resting heart rate and blood pressure.
Strive for at least 150 minutes of moderate or 75 minutes of
vigorous activities like walking, jogging, swimming or biking each
week. Wolf suggests also varying the intensity and duration from
one day to the next.
Pilates When combined with cardio, helps to combat central adiposity
(associated with increased risk for heart disease). Also good for
improving circulation and lowering stress levels.
Can be done on the same day as cardio or on noncardio days in place
of strength training. To get a great at-home workout, check out the
new Core Body Reformer by Nautilus ($279; corebodyreformer.com).
Weight training Improves heart and lung function, enhances glucose
metabolism and lowers coronary disease risk factors. Stronger muscles
equal less stress on the heart, too, keeping blood pressure and resting
heart rate down.
Aim for a total-body workout two to three times a week. Try:
Personal Training With Jackie: XTreme Timesaver Training, led by
Jackie Warner (star of Bravo TV's Work Out and Thintervention) -- a
fast and effective total-body sculpt session in just 30 minutes.
Tai chi Reduces stress, anxiety, depression and mood disturbance,
according to research.
Wolf suggests making it a daily practice, if possible. Try:
BodyWisdom Media's Tai Chi for Beginners.
Yoga Helps to achieve higher heart rate variability and parasympathetic
control (signs of a healthy heart), as well as lower levels of cytokine
interleukin-6 (or IL-6 -- part of the body's inflammatory response
that's been linked to heart disease and other chronic conditions).
Aim for a short or more meditative yoga practice on the same day as
cardio and/or in place of your strength-training workout. (For an
energizing sequence, see "Instant Energy" on pg. 46.)
~~~~~~~~
By Alexa Joy Sherman
Illustrations By Christian Northeast
Copyright of Natural Health is the property of Weider Publications, LLC and its content may not
be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual
use.
GERONTOLOGY PROCESS PAPER
45