Comprehensive Gerontological Assessment-3

.docx

School

University of North Carolina, Wilmington *

*We aren’t endorsed by this school

Course

321

Subject

Medicine

Date

Apr 3, 2024

Type

docx

Pages

Uploaded by AdmiralWillpowerOstrich14 on coursehero.com

1 Comprehensive Gerontological Assessment (K.M.) University of North Carolina Wilmington NSG 321 – 804 Gerontological Nursing and End of Life Care Dr. Michael Youngwood February 4, 2024 Comprehensive Gerontological Assessment (K.M.)

2 The comprehensive gerontological assessment will include social and medical history and a current review of systems of the patient. I have also included in this paper subjective and objective information from the patient along with biographical, past, and present health status, a current medication list, and functional and mental status assessment data with a personalized care plan. Client Profile/Biographic Data K.M. is a 66-year-old married white female. She is a director of education at an elementary and middle school. She has two daughters. She and her husband adopted their youngest daughter, and their eldest daughter is biological. She has lived in a large coastal city in North Carolina since 2018 and retired from Massachusetts with her husband and youngest daughter (K.M., personal communication, January 31, 2024). Family Profile She lives with her 72-year-old husband, along with her dog and cat. Her youngest daughter lives half an hour away, and her brother owns a vacation home forty-five minutes away that he frequently visits with his family. Her oldest daughter lives in the northeast. K.M. does not have a power of attorney. Her executor is her husband; if anything happens to her husband, her co-executors are her two daughters (K.M., personal communication, January 31, 2024). Living Environment K.M. lives in a 2450 sq. ft. 2-story house with four bedrooms and 3 ½ baths. She bought the house brand new in 2016 and used it as a vacation home until 2018 when she moved down permanently with her family. The home is safe and free of major maintenance concerns. The main living space is on the first story, and there is a guest suite with a full bath above the garage. There is no basement as the water table level is too high. There are three entryways with three

3 steps per entrance. Her home is in a safe community with sidewalks and is approximately 100 feet from a lake. K.M. is building a new home in a separate community south of their current city. The couple decided to downsize; the house is 1500 sq. ft. and one story. She has decided to have raised toilet seats in her new home as she and her husband are getting older, and he recently had double knee replacement surgery (K.M., personal communication, January 31, 2024). Recreation/Leisure Activities K.M. enjoys walking the path along her community lake, going to the beach with her family, and collecting shells. During the winter, she knits, and during the summer, she likes making Sailor’s Valentines. She enjoys cooking for the family during the holidays (K.M., personal communication, January 31, 2024). Resources/Support Systems Used K.M. and her husband rely on each other. She is close with her youngest daughter, who visits frequently. She plans to retire in June 2024. K.M. is financially stable and has planned for her retirement. She receives a pension from her former job in Massachusetts, and as a couple, she and her husband collect his social security. She has a health insurance policy from her former employer and is also on Medicare. K.M. does not receive government assistance (K.M., personal communication, January 31, 2024). Daily Routine On a weekday, K.M. wakes up at 0600 and prepares for work. She takes her morning dose of metformin. Then, she showers daily and is ready within thirty minutes. Her husband has her coffee ready for when she leaves in the morning. K.M. travels twenty-five minutes to school, which begins at 0800. She explains she does “paperwork, visits her students, and attends meetings.” School ends at 1500, but she does not arrive home until 1630. She takes her dog

4 outside and waits for her husband to arrive home. He often prepares dinner for her before she gets home from work. They eat dinner and watch their favorite television shows together until 2100, which is when they both go to bed; she also takes her second dose of metformin and Lantus during this time (she takes Mounjaro on Sunday nights right before bedtime as well) (K.M., personal communication, January 31, 2024). Present Health Status K.M. is obese and has type II diabetes mellitus. She suffers from diabetic neuropathy in her feet with numbness, tingling, and intermittent pain, which worsens when she lays down. She denies that ambulating or standing in place worsens neuropathy. K.M. checks her blood sugar with her FreeStyle Libre, a continuous glucose monitoring system ( FreeStyle Libre Continuous Glucose Monitoring | FreeStyle Libre US , 2024). She states that the sensor lasts two weeks, and she checks her blood sugar five times daily. She has follow-up telehealth visits with her primary care provider every three months since beginning a new diabetic medication, Mounjaro (tirzepatide) injection ( What Is Mounjaro for Adults With Type 2 Diabetes | Mounjaro (Tirzepatide) , 2023). K.M. reports that she is up to date on her vaccines. Her first two COVID-19 vaccines were Moderna, and she has now received two Pfizer boosters. The CDC recommends Pfizer- BioNTech, Moderna, and Novavax, and immunocompromised patients may need additional doses to protect themselves against COVID-19 (Centers for Disease Control and Prevention, 2024). After turning sixty-five, she received her influenza and pneumococcal pneumonia vaccines in October 2023. She received her latest shingles vaccine during her last physical in January 2024 (K.M., personal communication, January 31, 2024). Past Health Status

5 Per K.M., past surgical history included wisdom teeth removed when she was eighteen years old and an uncomplicated C-section at 36 with her oldest daughter. She has not been recently hospitalized. Her medical history includes being diagnosed with hyperlipidemia and hypertension, but she does not take medication for either of them as they are well-controlled. She reports she had chicken pox as a child, and then in 2016 and again in 2019, she had shingles. K.M. does not smoke or use tobacco products. She drinks 1-2 glasses of beer every other month when she and her husband go on dates, during family functions, or on holidays (K.M., personal communication, January 31, 2024). Family History K.M. states that her deceased mother had a past medical history of leukemia and hypertension. Her mother passed away from a fall after hitting her head. Her father had a history of prostate cancer, hypertension, and type II diabetes mellitus. All three of her brothers also have hypertension. K.M.’s father and brothers are alive (K.M., personal communication, January 31, 2024). Medications K.M. reports she is compliant with her medications; the following is a list of her medications, including dose, route, frequency, and indication: Mounjaro (tirzepatide) 15mg subcutaneous injection weekly to lower HgbA1c and lower blood glucose. Lantus (insulin glargine) is an 18-unit subcutaneous injection daily to lower HgbA1c and blood glucose. Metformin 2000mg (takes two tablets in the morning and two tablets at night) oral to control blood glucose. Takes Tylenol (acetaminophen) 650mg orally once or twice a month as needed for headaches. ProAir RespiClick (albuterol sulfate 117mcg) inhalation powder as needed for

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help