Ibn Sina College for health sciences

Home Visit plan for elderly

Studantns :

Areej Al-Hawareen & Adel Mahareeq

I- Name: Roqaya M
-Age:79 years old
-Marital: Married
-Address:AL-Dahreya town- Hebron
-Illness: Heart failure , HTN and Rheumatoid arthritis .
V\S : BP: 100\60 mmhg
Wt: 80 kg
ht: 165cm

P: 76b\m
T: 36.6 c
BMI: 35.2 (over wt)

RR: 14 B\M

II-Physical Changes of aging:

- Integumentery system (skin) : (20 point)
As she said there is no any injuries or lesion in her skin , sometimes become edematous
specially in the legs and hands , and sometimes she c\o red rashes on her skin related to
unknown allergy .
As our observation her skin was bright brown , dry , dehydrated , thick , has wrinkles ,
brown spots was seen on her hand and face skin , warm with touch , no any lesion or
bed sore seen , slightly edematous and there is swelling in her legs .
Capillary refill : within 2 3 sca .
she has flat nails , the angel below 160 , nails toe was seen .

-Head : (hair, eyes, ears, mouth & teeth, nose ) :

As she said she c\o headache , mild pain , not continues and when she take Acamol she
become better .
As our observation her head symmetric in shape , norm cephalic, slightly pain with
palpation , no any history of injury or trauma in the head , she has gray hear distributed in
all scalp .
Eyes: as our observation Eyebrows are equally distributed, eyelashes curl outward, pupil
is black equal in size in both eyes , round in shape , react normally to light and
accommodation by constriction and dilation.

Visual acuity has decrease she cant see things which is far away , she dont use a glass ,
she dont c\o cataract .

Ear: as her daughter said that she has decrease in hearing acuity , she dont hear low
voices or whispering sound .
As our observation the external surface of ear are smooth, symmetric in size and shape,
no lesion presence on the external ear, ear canal is pink no discharge or foreign body,
moderate wax presence ( with age there are increased risk for wax accumulation then
reduce hearing conducting).
Mouth & teeth : as she said she has dental , she c\o dryness in her mouth , no any lesion
as our observation her gum redness in color , her lips dry , and there is whit patches on
the tongue , the tonsils slightly swelling and red in color (tonsillitis) .
Nose: it is in the mid line in the face and as she said she can smell any odder and
differentiate between them , no any complaining of discharge from the nose .
Respiratory system : as she said she has mild pain in the chest , not radiated it is localized
in the chest , not continues , and sometime feel of dyspnea .
As our observation chest shape is barrel and symmetric , RR: 14 breath\mint , wheezing
sound was heard with auscultation , resonance sound with percussion, mild pain with
palpation .
Cardiovascular system : as she said she has hx of HTN , heart failure and weakness in
heart muscle and she c\o general weakness .
As our observation no any sign of cyanosis or ecchymosis was seen , no any palpitation
with auscultation on apical , radial pulse was irregular with rate 76 beats\min .
Abdomen : as she said she has acute mild pain in abd. Not radiated it is localized in the
abd , sometime c\o diarrhea , gases and abd blotting .
As our observation abd color as all body , there is no any scar for injury or surgery in the
abd , no lesion , the umbilicus in the medal and there is no any discharge from it , bowel
sound heard by auscultation , and there is crepitation sound , tympanic sound with
percussion , mild pain , no any mass or tenderness with palpation .
Musculoskeletal system : as she said she c\o osteoporosis , and she has hx of rheumatoid
arthritis , and she has joint pain , she cant walk alone and she use wheel chair to move
from place to another , no any hx of fracture .

As our observation she dont has any deformities in her extremities , they are symmetric ,
and there is edematous in lower limps .
Neurological system : as her doughtier said sometime she become nervousness but
almost time she is quite , she has dementia , short memory not very good , but the long is
good .
As our observation she was quite , conscious , oriented to time , person and place ,
cooperative with us and has good response in all nerves .
Elimination :
bowel : she go to bathroom for evacuation 2-3 times daily , sometimes c\o diarrhea .
Urinary : she go to bathroom for voiding 5-6 times daily , and she c\o UTI she has
burning sensation , pain with voiding .

III- Environmental Assessment : (20 point)

1- Physical environment :
a-Housing condition :
-space : the house contain 3 rooms , 1 kitchen and 1 bathroom .
-lightning : there is good lightning in all the rooms , and good sun expositor and
ventilation .
The house located at major street , there are stirs for it but they are not safe for elderly
persona .
-privacy : the house has good privacy , no anyone can enter the house , and it isnt close
to the neighborhood .
-heat & ventilation : the house has good ventilation and expositor to the sun every room
has 2 windows .
b-Neighborhood : safe neighborhood , available transportation, access to shopping
facilities :
.

.

2- Psychological environment :
a-Cognitive status ; long & short memory, orientation , concentration & judgment ,
ability to engage in mathematical calculation.

In her short memory there is a problem sometime she forgot events that has soon
happened , but her long memory is very well and she remember all event that happened
from ago .
There is no any problems with her cognitive status , she is oriented to person, place and
time. She can concentrate and observed any significant changes that may happened in
the house . She is able to choose , act and to perform activates of daily living and she can
judge in many things .
b- Affective status :- presence of depression , dementia, saddened mood state ..
she has sign of dementia , no any sign of depression , sometimes she become
nervousness and has a change in her mood .
3Social environment :
a-Social network, number &frequency of contact :
she love people very much and she has a number of visitor every day .
b-Persons with whom the client has frequent contact & whom the client feels able to
call on for assistance : most one her daughter that she live with her , she assess her in all
her needs , and she also contact with her sons and she call them when she need any
helps.
c-Income:- adequacy for meeting basic needs as well as special needs arising from
specific health conditions .
they can meet all basic needs .
, 3 750
.

IV-Life style:
1-basic activities of daily living (BADLs) : ability to feed , bath , dress or self toileting ,
getting in or out of a chair or bed .
She cant do any things without assistant , her daughter help her in bathing ,dressing and
when go to bathroom , but she can eat with herself .

2-Instrumental activities of daily living (IADLs): household tasks such as shopping,

laundry, cooking &housekeeping, manage money .
She cant do any of these tasks , all thing on her daughter she do all tasks .

3-advanced activities of daily living (AADLs): abilities to engage in voluntary social ,

occupational , or recreational activities .
She cant do any of these activities .
4-medication : what medication the old person take, when & how these medication
are taken , the clients knowledge , of side effects & signs of toxicity .
She take more than one type of drug , she take drug for heart failure (Digoxin) ,
antihypertension drug (anapril ), antiallergic , antibiotic drug(metronidazol) , antiacid drug
also she take overcounter drug like Acamole and she take it every day as prescription
(mostly in the morning ) and she dont has enough knowledge about these drug , for
some drug she know why these taken and for what and how are taken but she dont
know its side effects for example , no any sign of toxicity was seen , but she is risk for it
because of the polypharmacy .
5- Nutrition :
1- Assess the client appetite, food favor, What the client eats, is her nutrition adequate
for older person to maintain health and prevent disease: her appetite is very well she
eats 3 meals a day, and she also take snakes between them .
She dont has a special diet she prefers all kinds , she eats every healthy food green
vegetables, fruits and meats she always has at least 2 types of fruit.
2-prepare a nutritional schedule for a whole day including three meals and snacks that
will meet an older about caloric needs for 1 day .

Breakfast

Cals Lunch

Cals

Dinner

Cals

88

162

70

120

550

25

25

117

162

70
2

Snakes total
 
130
!

Break
fast:
305

"

Lunch :
829

#$%&
60

Cals

1581
1581

Dinner
257

The old person need more than 1500 kcl daily , as we see in the nutrition assessment
schedule she take her need so her nutrition statues is good .

V= Health care system :

1-health insurance:
,
.
2-sources of health care :
.
VI-planning Nsg care for older client : (20 point )
1- Problem in priorities :
1- Risk for toxicity related to polypharmacy .
2- Risk for injury related to immobility and presence of stirs in the home (she is on
wheel chair ) .
3- Risk for altered systemic tissue perfusion related to heart failure .
4- Chronic joint pain related to rheumatoid arthritis .
5- Altered oral mucous membrane: dryness related to atrophy of the oral cavity
epithelium, decreased salivary gland activity, and dehydration .

Nsg Dx

Goals

Nsg Intervention

1-Risk for toxicity

related to
polypharmacy .

*primary

13provide teaching and Our goal partially

prevention of

information about drug met .

toxicity

kinds , how to use it ,

occurrence

and when , appropriate

dose prescription , and
drug inter action .
23ask assistant from
family member to give
older person drug .
33provide teaching for
sign of toxicity .
43check drug expired
date before giving any
drug .
53decrease number of
over the counter drug .

Evaluation

She understand
our instruction for
drug to prevent
toxicity .

Nsg Dx

Goals

Nsg Intervention

Evaluation

2-Risk for injury

related to
immobility and
presence of stirs in
the home (she is
on wheel chair ) .

Older person

13Recognize all risks

My goal partially

well be free

factors and causes of

met

from any

falls in older adults .

No any reports of

injury by

23 Assess the patient

decrease the

care environment

risk .

routinely for extrinsic

risk factors and
institute appropriate
corrective action.
33carefully move the
older person when
transferred from her
bed to wheel chair.
43use good safe
belt( ABC! D!E) when
set the pt on wheel
chair to prevent falling
from it
53Institute
recommendations for
falls prevention and
management consistent
with clinical practice
guidelines .

injury for the older

person .

Nsg Dx

Goals

Nsg Intervention

Evaluation

33 Risk for altered

Older person

My goal partially

systemic tissue
perfusion related
to heart failure .

well maintain

1-assess signs and

symptoms that may
specifically indicate a
decrease in cardiac output
such as irregular puls.
2-assess signs and
symptoms of diminished
systemic tissue perfusion
such as decrease in systolic
and diastolic BP.
3-perform actions to
reduce cardiac workload .
4-implement measures to
promote rest.
5-discourage smoking
(smoking has a
cardiostimulatory effect
cause vasoconstriction,
and reduce availability)

adequate
tissue
perfusion .

met .
She has normal
V\S , no any sign
of decrease
perfusion .

Nsg Dx

Goals

4-Chronic joint
pain related to
rheumatoid
arthritis .

Decrease pain 1- Determine how the

Our goal partially

for older

met .

person , and
provide
comfortable

Nsg Intervention
client usually responds to
pain.
2- Assess for nonverbal
signs of joint discomfort.
3-Assess verbal complaints
of pain. Location ,
radiation , severity and
type of pain .
4-Assess verbal complaints
of pain such as instruct or
assist client to support
affected extremity with
hands or pillows when
changing positions .
5- Consult physician if
above measures fail to
relieve joint discomfort

Evaluation

There is presence
of decreased pain
and sense of
comfortable .