Download Well Elderly Assessment - Trinity Valley Community College

Trinity Valley Community College
Associate Degree Nursing Program
Level I – Well-Elderly Case Study Rubric
Student Name: ____________________________________Date: ___________ Total Points: ______/ 26
Name of Facility:
Initials of Patient:
Area
Complete
2 pts
Partial
1 pts
Section 1. Assessment (Clinical Judgment)
1a. Assessment
Fills in blanks with
Fills in blanks with
Subjective Data
appropriate data
appropriate data
[≤ 4 inappropriate or [5-8 inappropriate
missing]
or missing]
total 4 pts
total 2 pts
1b. Assessment
Fills in blanks with
Fills in blanks with
Objective Data
appropriate data
appropriate data
Except ≤ 4
except 5-8
inappropriate or
inappropriate or
missing
missing
total 4 pts
total 2 pts
1c. Assessment
Highlights
Highlights
Abnormal Data
abnormal data
abnormal data
except ≤ 4 instances except 5-8 instances
of highlighting
of highlighting
normal data or not
normal data or not
highlighting
highlighting
abnormal data
abnormal data
Insufficient
0 pts
total 4 pts
Section 2. Nursing Dx (Clinical Judgment)
2a. Nursing Dx
3 Nursing Diagnoses
Formulate Three each with nursing
(Clinical
problem and its
Judgment)
supportive data AND
etiology
total 2 pts
Fills in blanks with
appropriate data
[>8 inappropriate or
missing]
total 0 pts
Fills in blanks with
appropriate data
except
>8 inappropriate or
missing
total 0 pts
1 Highlights
abnormal data
except
>8 instances of
highlighting normal
data or not
highlighting
abnormal data
total 0 pts
3 Nursing Diagnoses
Each with nursing
problem and its
supportive data AND
etiology except
missing 1 nursing
problem and
supportive data
AND/OR etiology
3 Nursing Diagnoses
Each with nursing
problem and its
supportive data AND
etiology except
missing >1 nursing
problem and
supportive data
AND/OR etiology
total 4 pts
2b. Nursing Dx
3 Nur Dx’s Labeled &
Prioritize
Prioritized by
(Pt Centered Care) Maslow’s Hierarchy
total 2 pts
2 Nur Dx’s Labeled &
Prioritized by
Maslow’s Hierarchy
total 0 pts
<2 Nur Dx’s Labeled
& Prioritized by
Maslow’s Hierarchy
Total 1 pt
Total 0 pts
Total 2 pts
Weight
Points
[weight X2]
Total Possible: 4
Earned:
[weight X2]
Total Possible: 4
Earned:
[weight X2]
Total Possible: 4
Earned:
[weight X2]
Total Possible: 4
Earned:
[weight X1]
Total Possible: 2
Earned:
1
Area
Complete
2 pts
Section 3. Environment (Safety)
Environment
List of identified
(Safety)
hazards AND
corresponding
recommendations. If
environment is
hazard-free, then
writes one
paragraph
describing the
environment
Total 2 pts
Section 4. Nutrition (Critical Thinking)
Nutrition
Lists two or more
(Critical
nutrition
Thinking)
recommendations.
Partial
1 pts
Insufficient
0 pts
List of identified
hazards AND
corresponding
recommendations,
except missing 1
hazard/recommend
ation OR 1
inappropriate
recommendation.
OR If environment is
hazard free and
environmental
descriptive
paragraph is two to
four sentences.
List of identified
hazards AND
corresponding
recommendations
Missing ≥2 hazard
AND/OR incorrect
recommendation OR
if environment is
hazard-free and
descriptive
paragraph is less
than two sentences.
Total 1 pt
Total 0 pts
Lists one nutrition
recommendation
Missing nutrition
recommendations
Total 2 pts
Total 1 pt
Section 5. Team work & Collaboration (Critical Thinking)
Team work &
Identifies 5 or more
Identifies 3 or 4
Collaboration
resources already
resources already
(Critical
available that is used available that is used
Thinking)
or not used by the
or not used by the
client.
client.
Total 0 pts
Total 2 pts
Section 6. APA References
APA References All references
alphabetized with
APA format:Author,
year, title, and
journal.
Total 1 pt
Total 0 pts
All references
alphabetized with
APA format except
one or two kinds of
errors made of
author, year, title,
journal.
All references
unalphabetized
and/or with APA
format except three
or more kinds of
errors made of
author, year, title,
journal.
Total 1 pt
Total 0 pts
Total 2 pts
Identifies 2 or fewer
resources already
available that is used
or not used by the
client or omits
paragraph.
Weight
Points
[weight X1]
Total Possible: 2
Earned:
[weight X1]
Total Possible: 2
Earned:
[weight X1]
Total Possible: 2
Earned:
[weight X1]
Total Possible: 2
Earned:
2
Trinity Valley Community College
Associate Degree Nursing Program
Level I – Well-Elderly Case Study
Section 1. Assessment
Section 1a. Subjective Data
Demographics: Healthcare Concept – Diversity
Age: _____
Gender: _____ Race: _____________ Hispanic/Latino Ethnicity:  Yes  No  Unknown
Ethnicity: _______________ Religion: ______________Do your spiritual beliefs apply to your health?
 Affects treatment decisions  End-of-life care  Special dietary needs  Use of Faith/Folk healer
 Other: __________________________________________________________________________
Education completed: _______________________________________________________________
Social Support Assessment: Healthcare Concept - Coping
Emotional support available:  Yes  No Support System (Especially when there are problems)
 Case worker  Children  Family  Friend  Guardian  Pet  Religious leader  Sibling Spouse
 Support group  Therapist  Other: ___________________________
Health History:
Medical History: _____________________________________________________________________
Surgical History: _____________________________________________________________________
Accidents or Injuries: _________________________________________________________________
How do you define health? _____________________________________________________________
View of own health now:_______________________________________________________________
What are your concerns? _______________________________________________________________
What are your health goals? _____________________________________________________________
Allergies: Healthcare Concept - Immunity
Comments: ____________________________________________________________
Communicable Diseases: _______________________________________________________________
Childhood Illnesses: ___________________________________________________________________
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Immunizations:  Shingles vaccine / Date received: ______  Pneumococcal vaccine / Date received: ______
 Influenza (flu) vaccine /Date received: ______
 Tetanus, diphtheria, pertussis (Tdap) vaccine / Date received: _________
Current Medications:
Medication Name
Medication Reason
Dosage
Frequency
*Able to verbalize all home medications:  Accurately  Inaccurately
*Manages medication administration:  Independently  Effectively with assistance
Family History Assessment
Heart Disease
High Blood Pressure
Stroke
Diabetes
Blood Disorders
Cancer
Sickle Cell Anemia
Arthritis
Obesity
Kidney Disease
Tuberculosis
Mental Illness
Seizures
Alcohol/Drug Abuse
Self
Mother
Father
Grandparents
Siblings
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Nutritional Screen: Healthcare Concept – Nutrition
Usual Weight: ___________ Appetite:  Good  Fair  Poor  Other: _________________
Unintentional weight change greater than 10 lbs. in the last 6 months:  Yes  No
Weight gain:  Yes __________  No
Weight loss:  Yes _________  No
Diet:  NPO  Regular  Bland  Diabetic  Dysphagia  Ground  Kosher  Low cholesterol
 Low fat  Low sodium  Mechanical soft  No added salt  Pureed  Renal  Vegetarian
Eating difficulties:  Chewing  Loose teeth  No teeth  Swallowing  Dentures (poor fitting)
If eating difficulties present, describe the problem: ______________________________________________
_______________________________________________________________________________________
Nutritional Risk Factors
Constipation
Eating Disorder
Enteral Feedings
Impaired Nutritional Intake
Fluid intake < 50% of normal in last three days
Nausea/Vomiting/Diarrhea
History of Skin Breakdown/Decubitus Ulcers
Time
Yes
If yes, ask and describe history of problem
Food Intake History (24-Hour recall)
List foods consumed
Method of Preparation
Serving
Breakfast
Lunch
Afternoon snack
Dinner
HS snack
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Functional Assessment: Healthcare Concept – Functional Ability
Functional
Assessment
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
ADL Index Score
Independent (2)
Requires assistance (1)
Dependent (0)
Comment
Total
12 = Total independence
6 = Moderate independence
0 = Maximum dependence
Instrumental Activities of Daily Living (IADL):
(The first answer in each case indicates independence, the second capability with assistance, the third; dependence
The maximum score is 21. Declining scores over time reveal deterioration)
Ability to use telephone: (3) Operates telephone on own initiative; looks up and dials numbers, etc. () Dials a few
well known numbers (1) Answers telephone but does not dial (0) Does not use telephone at all
Shopping: (3) Takes care of all shopping needs independently (2) Shops independently for small purchases (1)
Needs to be accompanied on any shopping trip (0) Completely unable to shop
Food preparation: (3) Plans, prepares and serves adequate meals independently (2) Prepares adequate meals if
supplied with ingredients (1) Heats and serves prepared meals or prepares meals but does not maintain adequate diet
(0) Needs to have meals prepared and served
Housekeeping: (3) Maintains house alone or with occasional assistance (2) Performs light daily tasks but cannot
maintain acceptable levels of cleanliness (1) Needs help with all home maintenance tasks (0) Does not participate in
any housekeeping tasks
Laundry: (2) Does personal laundry completely (1) Launders small items; rinses socks; stockings; etc. (0) All
laundry must be done by others
Mode of Transportation: (3) Travels independently or drives on vehicle (2) Arranges own travel via taxi, but does
not otherwise use public transportation (1) Travel limited to Taxi or car, with assistance of another (0) Does not
travel at all
Responsibility for own medication: (2) Is responsible for taking medication in correct dosages at correct time (1)
Takes responsibility if medication is prepared in advance in separate dosages (0) Is not capable of dispensing own
medication
Ability to handle finances: (2) Manages financial matters independently; collects and keeps track of income (1)
Manages day-to-day purchases, but needs help with banking, major purchases, etc. (0) Incapable of handling money
IADL Total: __________
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Sleep Assessment: Healthcare Concept – Sleep
Average hours of sleep______ Usual bedtime: _______ Usual awake time: _______
Do you feel rested after you sleep?  Yes  No
Quality of sleep:  Poor  Fair  Good  Poor
Sleep problems:  Difficulty falling asleep  Difficulty remaining asleep  Night awakenings  Nightmares
Pain Assessment: Healthcare Concept - Comfort
Pain History:
Location: Where is your pain? ____________________________________________________________________
Quality: Tell me what your discomfort feels like______________________________________________________
Intensity: On a scale of 0-10 with “0” representing no pain and “10” representing the worst possible pain, how
would you rate your pain? ________________________________________________________________________
Pattern: When did or does the pain start? ____________________________________________________________
How long have you had the pain, or how long does it last? _____________________________________________
Do you have pain free periods? When? And for how long? _____________________________________________
_____________________________________________________________________________________________
Precipitating factors: What triggers the pain or makes it worse? __________________________________________
Alleviating factors: What measures or methods have you found helpful in lessening or relieving the pain?
_____________________________________________________________________________________________
Effect of
pain on:
Daily life
Sleep
Appetite
Relationships
Emotions
Concentration
None
Very mild
Mild
Moderate
Severe
Very Severe
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Section 1b. Objective Data
Height: ________ Weight: ________ Ideal body weight (range): _______________________________
Vital signs: T: _____ P: _____ R: _____
B/P:___________ which arm? ______________________
Sitting: ___________________________________
Standing: ________________________________
General Appearance of the Client
Grooming Appearance:  Well  Fair  Poor  Disheveled
Hygiene Appearance:
Posture Appearance:  Normal  Relaxed  Stiff  Slumped
Speech:  Clear  Disorganized  Dysarthria  Expressive aphasia  Loud  Monotone  Rapid  Slow  Soft
Affect:  Anxious  Depressed  Elated  Happy  Irritable  Labile  Sad  Other: ______________________
Skin & Extremities Assessment - Healthcare Concept - Tissue Integrity
Skin Color:  Normal for ethnicity  Ashen  Cyanotic  Flushed  Jaundice  Pale  Mottled  Other
Variations in skin color:  Birthmarks  Calluses  Freckles  Moles  Stria  Other
If any variations present, document location: ______________________________________________________
Skin Temperature:  Warm  Cold  Cool  Hot  Other
Skin Turgor:  Elastic  Tenting  Other: ________________________________________________________
Nail Description:  Groomed  Bruised  Clubbed  Dirty  Yellow  Ridged  Smooth  Thick  Thin  Brittle
 Ingrown  Inflamed
Hair Description:  Absent on extremities  Absent on head  Alopecia  Coarse  Brittle  Dry  Fine  Oily 
Shiny  Soft
Musculoskeletal Assessment: Health Care Concept - Mobility
Gait: Steady  Asymmetrical  Dragging  High stepping  Jerky Shuffling  Spastic  Staggering  Stiff 
Unsteady  Wide based  Unable to assess  Other_________________________________________________
Evaluation of
bilateral muscle
strength
LLE
LUE
RUE
RLE
Evaluate hand grip
strength
Strength
Muscle Tone
Sensation
Range of Motion (ROM)
Patient follows instructions to release the hand when assessing grip strength:  Yes  No
* ROM – Document Full motion active or passive, limited motion active or passive, pain with movement, unable to move)
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 Asymmetrical
Muscle tenderness? If yes, document location and severity:
 Mild  Moderate  Severe
Joint tenderness? If yes, document location and severity:
Spinal Assessment:
Activity limitations?
Mini Mental Status Exam: Healthcare Concept – Cognition
5.) How old are y
9.) What does it mean to say, “A rolling stone doesn’t grow moss?”
10.) Subtract 3
Mental Status Exam Mini Score = _______________
(0-2 errors = intact, 3-4 errors = mild intellectual impairment, 5-7 errors = moderate, 8-10 errors = severe)
*Allow 1 more error if client has no grade school education
*Allow 1 fewer error if client has had education beyond High school
Sensory Function Assessment: Health Care Concept - Sensory Perception
Perform Fingertip-to-nose Touch Test on patient (Estes; p. 752; 1-3 only):
Abnormal Comment:
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Fall Risk Assessment: - Healthcare Concept – Safety
Morse Fall Risk Assessment
Yes
No
Response points
History of Falling immediate or in the last three months
Yes response = 25
Presence of secondary diagnosis
Yes response = 15
Use of ambulatory aid
Furniture =30 Crutches,
cane, walker = 15
IV/Heparin lock
Gait/Transferring
Mental Status
Points
Yes response =20
Impaired = 20
Weak =10
Forgets limitations
= 15
Total Score:
0-44 indicates need for standard environmental safety precautions.
A score of 45 or > will add a problem “At Risk for Falls” to the problem
list. Please initiate the Fall Prevention Plan of Care.
Total
Assessment of Home Environment for Safety Hazards: Healthcare Concept – Safety
If yes; describe:
Is furniture
Is the
Healthcare Concept - Human Development
Erikson’s Stage:
Give one example of how the patient is meeting the above identified developmental stage:
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Section 1c.
(For sections 1a. and 1b. highlight, with a colored highlighter, each of the abnormal values for the subjective and
objective data.)
Section 2. Nursing Diagnoses
Section 2a. Formulate Three Nursing Diagnoses (RN Dx = P r/t E)
1.) Group the abnormal highlighted data in your assessment to support one problem (P) in the Health and Illness
Concepts Problem Table (see table 1-1). That one problem will be used as the “P” in one of the nursing diagnoses.)
Healthcare Concept
P = Problem (for nursing diagnosis)
Diversity
Communication: Verbal, Impaired
Coping: Family, Compromised
Decisional Conflict
Human Dignity, Risk for compromised
Spiritual Distress (Risk for)
Ineffective/Maladaptive Coping
Compromised Family Coping
Readiness for Enhanced Coping
Ineffective Community Coping
Ineffective protection
Impaired skin integrity
Risk for infection
Risk for allergy response
Knowledge deficit: Immune response
Bowel incontinence
Constipation
Perceived constipation
Risk for constipation
Diarrhea
Dysfunctional gastrointestinal motility
Risk for dysfunctional gastrointestinal motility
Urinary incontinence
Functional urinary incontinence
Overflow urinary incontinence
Reflex urinary incontinence
Stress Urinary incontinence
Urge urinary incontinence
Risk for urge urinary incontinence
Toileting, self-care deficit
Impaired urinary elimination
Readiness for enhanced urinary elimination
Urinary retention
Self-care deficit(s)
Impaired mobility
Impaired wheelchair mobility
Coping
Immunity
Nutrition
Functional Ability
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Sleep
Comfort
Tissue Integrity
Mobility
Cognition
Sensory Perception
Safety
Human Development
Sleep Pattern Disturbance
Sleep Deprivation
Readiness for Enhanced Sleep
Insomnia
Acute pain
Chronic pain
Impaired comfort
Readiness for enhanced comfort
Impaired skin/tissue integrity
Alteration in comfort, pain
Risk for injury
Risk for falls
Decreased mobility
Knowledge Deficit: personal safety or health
maintenance or treatment regimen
Acute confusion
Impaired Verbal Communication
Risk for Injury
Impaired Social Interaction
Sensory Perception Disturbance (specify: visual,
auditory, kinesthetic, gustatory, tactile, olfactory)
Altered role performance (specify: visual, auditory,
kinesthetic, gustatory, tactile, olfactory)
Social Isolation (specify: visual, auditory,
kinesthetic, gustatory, tactile, olfactory)
Body Image disturbance (specify: visual, auditory,
kinesthetic, gustatory, tactile, olfactory)
Impaired Communication (specify: visual, auditory,
kinesthetic, gustatory, tactile, olfactory)
Risk for injury
Risk for falls
Knowledge Deficit: personal safety or health
maintenance or treatment regimen
Acute confusion
Impaired ADL’s
Impaired physical mobility
Acute confusion
Chronic confusion
Delayed growth and development
Table 1-1 Health and Illness Concepts Problem Table
2.) Next, add the etiology to complete the nursing diagnosis.
Section 2b. Prioritize The Three Nursing Diagnoses
3.) Use Maslow’s Hierarchy of Needs Theory to identify which level the nursing diagnosis falls in.
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4.) Prioritize the Nursing diagnosis as First (most important), second, and third according to Maslow.
Do the above steps, one through four, for each nursing diagnosis. You will have a total of three nursing diagnoses.
Example:
The abnormal data: “I have a hard time moving around due to I have arthritis in both hips”
The concept: Healthcare concept – Mobility
The Nursing Diagnosis: Decreased mobility r/t joint pain
The identification according to Maslow’s Hierarchy: Physiological
The prioritization of the Nursing diagnosis: First
Section 3. Environment
Provide recommendations for all identified safety, environmental and/or hazardous problems from the “Assessment
of Home Environment for Safety Hazards” in this case study form. Complete one paragraph describing all hazards
identified; if no hazards identified, then writes one summary paragraph.
Section 4. Nutrition
Critical Thinking Exercise:
Analyze the “Food Intake History” that is in this case study form, and make recommendations for healthy food
choices.
Section 5. Team Work and Collaboration
Critical Thinking Exercise:
Because of the increasing number of older adults, identify 5 resources already available that are needed in your
community in order to assist with this growing population.
Section 6. APA Style References
For examples and explanations visit the following link: http://owl.english.purdue.edu/owl/resource/560/01/
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