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ELDERLY

Joshepin Carmino is a 66-years-old woman who lives alone in a small urban


appartment. She lived on a fixed income from her decreased husband’s Social Security.
She has come to the clinic for her routine check up. During the initial interview, you
notice that she doesn’t always answer your question appropriately and she talks very
softly when she offers information spontaneously. When you check her hearing with the
wishper test, she asks you to repeat several times, and finally tells you, with annoyance in
her voice, that “ you just have to speak up if you expect people to hear you ! “. When you
do the Rinne test, the result BC>AC. When questioning her about problems, she denies
having any hearing loss. She says she never had eudiometry and she cant afford it now.
She also tells you that she doesn’t talk to friends on the telephone anymore, because they
don’t talk loud enough.

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A. Assessment
1. Biographical Data
Name : Mrs. J C
Address :
Birth of Date :
Age : 66 years old
Gender : female
Race/Ethnic :
Level of Education :
Occupation :
Marital Status : Married
Phone :
History of Illness :
Chief Complaint : Patient tells that she doesn’t talk to friends on the telephone
anymore, because they don’t talk loud enough

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2. Head To Toe Physical Examination

a. GENERAL CONDITIONS OF PATIENTS


Awareness :
Vital Sign :

b. HEAD :

c. SKIN :

d. VISION :

e. SMELLING/NOSE :

f. HEARING/EAR : Rinne test BC>AC

g. MOUTH :

h. NECK :

i. CHEST/BREATHING :

j. ABDOMINAL :

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k. REPRODUCTION SYSTEM :

l. UPPER/LOWER EXTREMITY :

3. Physical, Psychological, Social, Spiritual Needs

a. NUTRITION :

b. PSYCHOSOCIAL : patient gets loss social interaction

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4. ROS Assessment
Respiratory System (B1) Cardiovascular System (B2)

Nervous system (B3) Genito Urinary System (B4)

Gastrointestinal system (B5) Bone – Integumen – Musculosceletal


(B6)

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Reproductive system Psychososial

Patient gets loss social interaction

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B. Data Analysis
No. Data Focus Problem Etiologi
1.  Patient doesn’t always answer Ineffective Auditory hearing loss
question appropriately relationship
 When checking patient’s hearing
with the wishper test, she asks to
repeat several times
 The result of Rinne test is BC>AC

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C. Nursing Diagnoses and Intervention
GOAL INTERVENTION RATIONALE OUTCOME
1. Ineffective relationship related to auditory hearing loss

 Assess the level  Patient


 Patient can  Knowing of
of patient’s interacts
interact well patient’s hearing
ability to receive well
ability
messages  Patient can
 Speak with
understand the
patient clearly
conversation
and slowly  Helping the
 Use the writing
patient to
tool if needed
understand the
conversation