A.T 65 year old female
Hearing:
Assessment: -patient denies hearing loss -patient has a history of smoking, she states "I smoked 2 packs a day for many years but quit last year May.", -patient uses Q-tips to remove wax bilaterally, -patient shows no signs of vertigo or dizziness, -patient ears look equal bilaterally with no foreign bodies present
Risk factors: -impacted wax -history of being a smoker
Health Promotion: -Limit exposure to loud noise -be careful with the use of Q-tips -do not put anything deep into the ear canal
Nursing Diagnosis: Readiness for enhanced knowledge related to use of foreign objects entering the ear
Vision:
Health promotion: Protect eyes from sunlight, get regular eye exams as recommended by doctor.
Nursing Diagnosis: readiness for enhanced self care related to vision changes secondary to diabetes.
Outcomes: Patient will identify way to control diabetes and decrease its affect to eyes.
Interventions: Encouraging eye exams and monitor nutritional habits and blood sugar levels.
Objective: PEERLA, No swelling noted, conjunctive pink, sclera white, cranial nerves III,IV, VI and intact.
Risk factors: History of smoking, nutritional deficit
Subjective: report vision changes in last 2 years, patient wears glasses, denies falls related to vision, history of smoking but quit last year after heart attack, and glasses change to sunglasses when exposed to the sun.
Age related: decreased tear production, decrease elasticity in eyelids, degenerative changes in all structures.
Sleep/Rest:
Risk factors: Anxiety/Depression,environment, pain and discomfort
Age related: Difficulty falling asleep, decrease in REM sleep, decrease in sleep time.
Health Promotion: Decrease caffeine intake, use soothing music, use bathroom before bed, sleep in dark room
Nursing diagnosis: readiness for enhances sleep patters related to difficulty falling asleep.
Outcome: Patient reports falling asleep within 20-25 minutes of going to bed in the next 3 weeks.
Interventions: educate on proper sleep behaviors , keep sleep log, explain importance of decrease in caffeine before bed.
Assessment: Patient wakes up tired, bed time is at 10 PM and she wakes up at 4 AM, watches television before bed, drinks about 4 cups of coffee throughout the day, history of smoking, rates sleep 6/10.
Sexual Function:
Risk factors: medications, functional impairments
Age related: degenerative changes in reproductive organs, decrease in hormone production erectile dysfunction.
Subjective:Patient states she has 3 children, denies any abnormal discharge, patient has no period, no HX of STD or HIV, no family HX of reproductive cancers, no HX of cysts, previously married.
Nursing Diagnosis: readiness for enhanced knowledge related to the importance of STD or HIV prevention of AEB regular check ups and use of protection.
Outcome: patient will verbalize and understanding of using protection during sexual activity.
Interventions: educate on using protection during sexual intercourse, educate for regular check ups, and sexual testing recommended for those who are sexually active.
Thermoregulation:
Risk factors: medications, environment, caffeine/alcohol consumption
Health promotion: Wear layers of clothing when appropriate, avoid/limit caffeine and alcohol intake, maintain adequate nutrition/hydration.
Age related: decrease shivering and sweating, peripheral circulation.
Assessment: temperature 97.6 , utlizes A/C and heat in home and in car, wears multiple layers to sleep, hands are always cold weather bothers joints, home is properly ventalated.
Nursing Diagnosis: readiness for enhance knowledge related to staying warm during winter and cool during summer.
Outcome: engage in behaviors to maintain comfortable temperatures.
Interventions: educate about proper nutrition and educate on signs and symptoms of hypo/hyperthermia.
Age related: increased keratin, calcified ossicles, degenerative changes in auditory nervous system.
Outcomes: patient will verbalize understanding of how to properly clean ear wax out of ear and schedule a yearly check up within the next 2 weeks.
Interventions: remove excess or impacted cerumen if present, reduce exposure to loud noises, having a hearing test done yearly to assess hearing.