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80 y/o female Hearing, Vision, Sleep/Rest, Thermoregulation, and sexual…
80 y/o female
Hearing, Vision, Sleep/Rest, Thermoregulation, and sexual function.
Sleep / Rest
WELLNESS DIAGNOSIS
Improved quality of life r/t inadequate sleep AEB verbalization of being chronically tired.
INTERVENTIONS
Teach about good sleep hygiene, and when to take medications so they do not interfere with sleep. Teach about going to bed around the same time for better rest.
OBJECTIVE
Pt appeared tired, although no confusion was present. Pt was sitting in recliner with legs elevated.
AGE RELATED CHANGES
Decrease time in deep sleep, and time spent in dreaming state. increase time in light sleep.
RISK FACTORS
Pain or discomfort nocturia. Anxiety/depression. Adverse medication reaction that impedes sleep. Pathologic conditions, and environmental factors.
SUBJECTIVE
Pt states she wakes up chronically tired and does not feel likes she slept enough. Pt states she only sleeps approx. 3-5 hrs a night while waking up once to use the bathroom. Pt also states she will fall asleep in her recliner and takes throughout the day. She taps about 2 naps during the day. Pt says she try to go to bed around the same time every night although that does not seem to help her quality of sleep.
MEDICATIONS
Pt is one a few medications to lower blood pressure and prevent future strokes. The list goes as following; ASA, Atrovastatin, Aggrenox, Vitamin D, lasix, fish oil, and Carvedilol
Thermoregulation
WELLNESS DIAGNOSIS
Improved quality of life r/t inadequate sleep AEB verbalization of being chronically tired.
INTERVENTIONS
Maintenance of environmental temperature, comfort measures, teaching about hypothermia/hyperthermia.
OBJECTIVE
Pt is wearing a long sleeve sweatshirt and long pants with slippers. Thermostat is set to 72 degrees F. Pt is sitting in recliner and half way through out interview covers up with a thin blanket.
AGE RELATED CHANGES
Decrease in subcutaneous tissue, shivering, ability to acclimatize to heat, decrease in sweating, peripheral circulation, and inefficient vasoconstriction.
RISK FACTORS
75 or older, adverse environmental conditions, alcohol & medication reaction, chronic diseases.
SUBJECTIVE
Pt states she is usually cold, but she wears extra layers to maintain and adequate body temperature. Pt also elevated the heat within her house to maintain warmth. Pt says she has a harder time staying warm in the winter due to having an older house and cold air drifts through the windows.
MEDICATIONS
Pt is one a few medications to lower blood pressure and prevent future strokes. The list goes as following; ASA, Atrovastatin, Aggrenox, Vitamin D, lasix, fish oil, and Carvedilol
Sexual Function
WELLNESS DIAGNOSIS
Improved quality of life r/t inadequate sleep AEB verbalization of being chronically tired, and not wanting sexual relations.
INTERVENTIONS
Teach about age related changes, addressing risk factors, teaching about horomonal therapy.
OBJECTIVE
Pt answered questions, although appeared to not want to talk about it, so interview on this topic was short.
AGE REALTED CHANGES
Degenerative changes in all reproductive organs, diminished levels of hormones, and cessation of menses.
RISK FACTORS
Stereotypes and misconceptions , limited opportunities, adverse reaction to medications, functional impairments, and chronic illness.
SUBJECTIVE
Pt was not very receptive or open with talking about sexual relations. She states her and her husband can not really do that because of functional abilities. They do like to kiss and hold hands. She does not remember when she had her first menses and can not recall her last although she thinks it was about 25 years ago. So approx. when she was in her mid 50s. Pt denies vaginal pain or tenderness. Pt does get regular gynecological exam and breast exams.
MEDICATIONS
Pt is one a few medications to lower blood pressure and prevent future strokes. The list goes as following; ASA, Atrovastatin, Aggrenox, Vitamin D, lasix, fish oil, and Carvedilol
Hearing/Vision
WELLNESS DIAGNOSIS
Readiness for enhanced knowledge r/t vision and hearing AEB pt verbalization or needing education about hearing.
INTERVENTIONS
Teaching about signs and symptoms of hearing and vision loss. Teaching about having regular check ups and having ears and eyes checked. Teach about not using Q-tips and ways to clean ears. Teach about eye drops when necessary for dry eyes. Teach about risk factors. Teach about wearing sunglasses when outside.
OBJECTIVE
Pt was able to hear when asking questions and responded appropriately, and was able to visualized handouts, read and understand information. Eyes PERRLA.
AGE RELATED CHANGES
Increased keratin, stiffer membranes in the ear, calcified ossicles, degenerative changes in the auditory nervous system and structures of visual function. Decreased elasticity in eyelids, tear production. increased in opacity of lens.
RISK FACTORS
Impacted ear wax, exposure to loud noises, ototoxic medications & adverse medication reaction, smoking, chronic diseases. Glare, poor lighting, exposure to ultraviolet rays, and nutrient deficiencies.
SUBJECTIVE
Pt states she is hard of hearing, although had a hearing aid but no longer likes to use it. Pt does wear her glasses and can see with them on. She is unaware how bad her eye sight truly is because she constantly wears her glasses. Pt does not know when last hearing or vision test occurred on. Pt denies exposure to load noises, or smoke. Pt denies ringing in eyes, and dizziness. Pt denies blurred vision, floaters, and any other eye abnormalities.
MEDICATIONS
Pt is one a few medications to lower blood pressure and prevent future strokes. The list goes as following; ASA, Atrovastatin, Aggrenox, Vitamin D, lasix, fish oil, and Carvedilol