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NURS 420: Gero Assessment; p 1 of 17
Part 2. Data Collection Sheet / Intake Form (20 points)
Client Initials: KV
M/F: Male
Age: 84
Student: Kris Brokke
Date: 9/15/17
NOTE: short responses and/or bullets are sufficient for this project; word process right in the table cells and let the paper expand as needed.
Introduction Questions:
1. Would you rate your
current state of health as
excellent, good, fair, or
poor?
2. Why did you select this
rating?
3. What does it mean to be
healthy as you age?
“I would rate my current health status as good, I do not have any complaints at this time.”
“I feel normal, no pains right now. I just take a few medications for my health.”
“It is important to me at my age to have good health. It means I am free of disease or infections…that sort of
stuff.”
Criteria
1. Current health problems
and their functional impact.
Client Findings
Health Problems
Functional Impact
1. Asthma
Waking up during the nighttime occasionally with
2. High Cholesterol
breathing issues.
3. Benign Prostatic Hyperplasia (BPH)
Blood pressures, at times, have been elevated.
Waking up during the nighttime, very frequently,
with bladder issues (polyuria).
2. Current medications, their
indications and effects.
Medications
Nurses Only: (precautions)
-Adverse Effects, Target goal, Lab Monitoring
1. Symbicort
2. Zocor
3.Tylenol
4. Flomax
5. Preservision
Fall.2017.njs©
Indication
1. Symbicort is used to prevent
bronchospasms for people
who suffer from asthma or
chronic obstructive
pulmonary disease.
Symbicort: Precautions: adrenal suppression related,
asthma related, bone density, bronchospasm,
hypersensitivity reactions, lower respiratory infections,
oral candidiasis, serious effects/fatalities, vasculitis;
cardiovascular disease such as elevation of blood pressure
NURS 420: Gero Assessment; p 2 of 17
6. Bayer, low
dose aspirin
2. Zocor is used to lower
cholesterol and triglycerides
in the blood.
3. Tylenol is a pain and fever
reducer.
4. Flomax is used to improve
urination in men with BPH.
5. Preservision is a daily
multivitamin formulated to
promote eye health.
6. Bayer, low dose aspirin is
used to treat pain, and
reduce fever or
inflammation. It is
sometimes used to treat or
prevent heart attacks,
strokes, and chest pain
(angina).
(Davis Drug Guide, 2017)
and heart rate causing CNS excitation, flattening of the T
wave, prolonged QTc interval, ST segment depression;
COPD – do not use with acute episodes; Diabetes – beta
agonists may increase serum glucose and aggravate
preexisting diabetes mellitus and ketoacidosis; hepatic
impairment – may lead to accumulation of drug itself;
hypokalemia – beta 2 agonists such as formoterol
decrease serum potassium; ocular disease – may cause
increase in intraocular pressure in patients with glaucoma
or cataracts; seizure disorders – beta agonists may
exacerbate as they cause stimulate CNS activity; thyroid
disease – steroid clearance changes based on hyper- or
hypothyroidism.
Budesonide may result in serious side effects or lead to
death. Formoterol can cause affect heart rhythm
abnormalities. EX: QT-interval prolongation, which can
lead to Torsades de Pointes, which can trigger ventricular
fibrillation. Budesonide can lead to immune suppression
as it is a steroid. If stopped too quickly, it may lead to
Addisonian Crisis’-like symptoms (extreme fatigue, weight
loss).
Adverse effects: CNS – headache; Respiratory –
nasopharyngitis or URI, pharyngolaryngeal pain;
Gastrointestinal – abdominal distress, oral candidiasis,
vomiting; Infection – influenza
Target Goal – We want to see the Symbicort exerted full
effect of its steroid (budesonide) and beta 2 agonist
(formoterol) components. The long acting beta 2 agonist
will lead to longer relief from bronchospasm. The
corticosteroid will prevent the bronchioles from becoming
irritated and inflamed, furthermore, allowing the patient
to much more easily breathe from day to day. The
mechanism of action of formoterol is to bind agonistically
bind the beta 2 receptor of the bronchioles to promote
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NURS 420: Gero Assessment; p 3 of 17
bronchodilation. The mechanism of action of budesonide is
to depress the migration of polymorphonuclear leukocytes,
fibroblasts; reverses capillary permeability and lysosomal
stabilization at the cellular level to prevent or control
inflammation. Has potent glucocorticoid activity and weak
mineralocorticoid activity.
Labs: Check CBC, CMP
Zocor Precautions: Diabetes – increases serum glucose
and HbA1c. Hepatotoxicity – get liver function tests at
baseline to assess appropriately. Immune mediated
necrotizing myopathy – may persists even after the
discontinuation of statin therapy.
Myopathy/rhabdomyolysis – this is more prevalent when
using other lipid lowering therapies, age> 65, female
gender, uncontrolled hypothyroidism, and renal
dysfunction, colchicine use. Avoid in patients who
consume large amount of alcohol. Avoid high dosage in
Chinese patients if concurrently taking Niacin >1g/day.
Adverse Effects: Cardiovascular – atrial fibrillation,
edema; CNS – headache, vertigo; Dermatologic –
eczema; Gastrointestinal – abdominal pain, constipation,
gastritis, nausea; Genitourinary – cystitis; Hepatic –
increased LFTs (3x UL); Neuromuscular and Skeletal –
increased CPK, myalgia; Respiratory – URIs, bronchitis
Target goal of Zocor, a statin medication, is to lower LDL,
cholesterol, triglycerides. The medication can also raise
HDLs. Target goal of HDL is 60 or more men. LDL is less
than 150 is a healthy male.
Labs: Check LFTs, CPK and myoglobin, Lipid profile
Tylenol Precautions: Hepatotoxicity- do not exceed
>4g/day; hypersensitivity/anaphylactic reaction –
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NURS 420: Gero Assessment; p 4 of 17
discontinue if signs of these reactions occur; skin
reactions – beware of stevens Johnson, toxic epidermal
necrolysis, ;ethanol use – avoid taking medication during
acute or chronic alcohol consumption;G6PD deficiency;
hepatic impairment ;hypovolemia – not safe in the
severely dehydrated patient; malnutrition ;renal
impairment
Adverse Effects: Dermatologic – skin rash; Endocrine and
Metabolic – decreased sodium bicarbonate, decreased
serum calcium, decreased serum sodium, hyperchloremia,
hyperuricemia, increased serum glucose; Genitourinary –
nephrotoxicity in chronic overdose; Hematologic and
oncologic – anemia, leukopenia, neutropenia,
pancytopenia; Hepatic – Increased Alk Phosphatase,
increased Bilirubin; hypersensitivity – hypersensitivity
reaction; Renal – hyperammonemia, renal disease
Target goal – Medication is working to reduce somatic
pain and fever. inhibit the synthesis of prostaglandins in the
central nervous system and work peripherally to block pain
impulse generation; produces antipyresis from inhibition of
hypothalamic heat-regulating center
Labs: Check LFTs if patient has precautions
Flomax Precautions: Angina – discontinue if symptoms
occur or worsen; floppy iris syndrome – may occur
intraoperatively during ophthalmic surgery potentially
causing complications. Patient should advise medical
professional that they are on Flomax prior to surgery.
Orthostatic hypotension: avoid if using other antihypertensives especially vasodilators like PDE-5 inhibitors
(sildenafil, tadalifil, vardenafil. Advised about performing
hazardous tasks such as driving and operating heavy
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NURS 420: Gero Assessment; p 5 of 17
machinery; priapism – rarely occurs; sulfonamide allergy
– avoid if ever had a reaction to Sulfa; heart failure – may
exacerbate underlying myocardial dysfunction; prostate
cancer – rule out prostate carcinoma before initiation and
then screen at regular intervals.
Adverse Effects: Cardiovascular – orthostatic hypotension;
CNS – headache, dizziness, drowsiness, insomnia,
vertigo; Genitourinary – ejaculation failure; Infection;
Respiratory – rhinitis, pharyngitis, cough, sinusitis;
Endocrine and metabolic – loss of libido; Gastrointestinal
– diarrhea, nausea; Neuromuscular and skeletal –
weakness, back pain; ophthalmic – blurred vision
Target Goal: Medication is used to reduce nocturia and
intermittent stream. Works as an alpha 1 antagonist in
the prostate leading to relaxation of smooth muscle in the
bladder neck.
Labs: N/A
Preservision Precautions: Iron toxicity, hepatic
impairment, renal impairment, ethanol
Adverse Effects: abdominal pain, vomiting, constipation,
diarrhea
Target Goal: Patient may take this on a voluntary basis
Labs: N/A unless Iron toxicity is suspected
Bayer low dose aspirin precautions: Salicylate toxicity if
sensitive to tartrazine dyes, nasal polyps, and
asthma; tinnitus; upper GI bleeding; bleeding
disorders, dehydration, ethanol use, GI disease,
hepatic impairment, renal impairment; do NOT use
with alteplase in treatment of ischemic stroke within
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NURS 420: Gero Assessment; p 6 of 17
if given within 24 hours; do NOT use with other COX2 inhibitors/NSAIDs
Adverse Effects: Cardiovascular – Cardiac arrhythmia,
edema, hypotension, tachycardia
Central nervous system – Agitation, cerebral edema, coma,
confusion, dizziness, fatigue, headache, hyperthermia,
insomnia, lethargy, nervousness, Reye’s syndrome
Dermatologic – Skin rash, urticaria
Endocrine & metabolic – Acidosis, dehydration,
hyperglycemia, hyperkalemia, hypernatremia (buffered
forms), hypoglycemia (children)
Gastrointestinal – Gastrointestinal ulcer (6% to 31%),
duodenal ulcer, dyspepsia, epigastric distress, gastritis,
gastrointestinal erosion, heartburn, nausea, stomach pain,
vomiting
Genitourinary – Postpartum hemorrhage, prolonged
gestation, prolonged labor, proteinuria, stillborn infant
Hematologic & oncologic – Anemia, blood coagulation
disorder, disseminated intravascular coagulation, hemolytic
anemia, hemorrhage, iron deficiency anemia, prolonged
prothrombin time, thrombocytopenia
Hepatic – Hepatitis (reversible), hepatotoxicity, increased
serum transaminases
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NURS 420: Gero Assessment; p 7 of 17
Hypersensitivity – Anaphylaxis, angioedema
Neuromuscular & skeletal – Acetabular bone destruction,
rhabdomyolysis, weakness
Otic – Hearing loss, tinnitus
Renal – Increased blood urea nitrogen, increased serum
creatinine, interstitial nephritis, renal failure (including cases
caused by rhabdomyolysis), renal insufficiency, renal
papillary necrosis
Respiratory – Asthma, bronchospasm, dyspnea,
hyperventilation, laryngeal edema, noncardiogenic
pulmonary edema, respiratory alkalosis, tachypnea
Target Goal: used as an analgesic, antipyretic, antiplatelet,
and anti-inflammatory. Irreversibly inhibits COX-1 and COX2 enzymes leading to decreased prostaglandin formation.
Labs: Check CBC if UGIB is suspected.
(Davis Drug Guide, 2017)
3. Previous surgeries and/or
health problems
Bowel blockage back in 2010, surgery to remove blockage completed the next day. Vertical scar noted on
abdomen. Shingles flare in 2013, successfully treated with Acyclovir. History of syncope, last instance was
back in 2014, when he passed out in a local pizza place. No injuries or residual affects noted. Does not
receive medication for this condition, but blood pressure medications were adjusted to help reduce the
occurrence.
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NURS 420: Gero Assessment; p 8 of 17
4. Recent and impending life
changes (deaths, moves,
stressors, hospitalizations)
Stressors concerning his son, Troy and the family farm during the harvest season of soy beans. States that
he thinks about it all day and it bothers him a lot during the day. He has never taken an antianxiety/depression medication in the past.
5. What activities engaged
in to maintain or improve
health? How does this affect
their personal and social
functionality?
He is very active, states, “I love walking at the mall, going to the YMCA to walk the track and participating in
all the activities that I can. I am not one for sitting around.” By being active, it allows him to maintain his
independence and have a healthy social life. States, “By being able to keep my independence, I feel like I am
much younger. I really hate relying on others for help, even though I know I may need help in the future, I
really like where I am now.” He also went on to talk about how having a social life makes it easier on him
emotionally, because “a lot of my friends have gone and passed away, but I enjoy being close to those
around me and going out for coffee every day.” Having a healthy social life is very important to him.
6. Current and future living
environment and its
appropriateness to ADL
function and long-term
prognosis? How does it
contribute to their health? Is
it appropriate? Any safety
concerns?
Lives at home with his significant other. At this time, he would like to remain at home, but knows that if his
needs become too great for him to handle he may need to move to an assisted living facility. He can
complete activities of daily living (ADL’s) appropriately. Long-term prognosis is good in his own words. He
does not have any artificial limbs, and rarely must climb down the stairs. He does not have a history of falls
in his home. Episodes of syncope have happened when out of house. This is still a major concern for him, as
well as myself. When assessed on how safe he feels, states, “I have good neighbors that are always willing to
help me out.” Resident seems to have anxiety as a result of this uncertainty, which raises his blood pressure
and heart rate. States, “When I start to worry about these type of things, I feel as though I could pass out. It
is really quite odd.” Resident’s memory assessed, I did notice issues when assessing home, resident’s health
history and past events. At times, recalling events would be very clear and then he would become confused
and change the entire story or event. He also states, “I cannot seem to remember faces or names very easily
anymore.” Resident stated that his family has a history of dementia, but he wasn’t sure if he had dementia.
7. Family situation and
Fall.2017.njs©
Both of his son’s live on their family farm located in Campbell, Minnesota. His daughter, lives minutes away in
NURS 420: Gero Assessment; p 9 of 17
availability. Provide details.
Fergus Falls, Minnesota. Sister and brother-in law, both live at a nursing home a few blocks away from where
he currently lives.
8. Current caregiver network
including its deficiencies and
potential for improvement.
9. Objective measure of
cognitive status,
forgetfulness, etc. Explain.
Caregiver network from Lake Region Hospital in Fergus Falls, Minnesota. Deficiencies: States, “I really cannot
complain, I feel as though I am very well taken care of. I can’t see anywhere they could improve.”
I have known him all of my life, and have seen his memory slowly decline. When assessing his memory, I
was actually alarmed at how much he had declined. He states, “I know I am very forgetful at times, I will
always know your name, but I have lots of trouble remembering other people’s.” He is alert and oriented x4,
with no complaints of headaches, pains in his neck/back region. Pupils equal, and reactive to light. When
using the General Practitioner Assessment of Cognition (GPCOG) tool, he scored a 7, which means he is
moderately impaired cognitively (Alzheimer’s Association, 2017).
10. Objective assessment of
mobility and balance.
Explain.
Throughout knowing him, he has been known to be very active in the community and in his yard work.
During my assessment, which was over 3-4 days of watching him complete ADL’s, I really do not have any
concerns regarding mobility, but as far as balance I fear that he may fall and break a hip or worse. He also
has a history of passing out, which could potentially be fatal if he falls down the stairs and hits his head. His
ROM is normal in all extremities and does not complain of pain. He is able to reach cupboards, drive his car
and walk the mall or YMCA with ease.
11. Rehabilitative status,
prognosis, how long they
can be expected to stay in
current living situation?
Assistance or home
modifications needed?
With his current living situation and comorbidities, he can be expected to stay in his current living situation
for at least another 5-6 years. He is a very active elderly man, with a great support system to make sure he
is staying healthy. If complications were to arise, he states, “I would like to go to the nursing home a few
blocks away and live with my sister.” Home modifications that may be needed are to install better lighting in
hallways and to install better, more tightly fastened hand rails on stair case. It would also be important for
him to have a button to call for help in case he fell and was not able to call for help.
12. Current
emotional/mental health and
substance use/abuse?
Explain.
Fall.2017.njs©
He has never been diagnosed with any psychiatric disorder. He has never taken an antipsychotic/depression
medication. When assessed on thoughts of suicide, he had stated that he had never once had suicidal
NURS 420: Gero Assessment; p 10 of 17
ideation. “The saddest I have ever been is when my first wife died, it was tough on me emotionally, but I was
able to get through it because of strong family and friend relationships.” He also stated that he had never
abused alcohol or drugs, but found himself becoming addicted to coffee (caffeine). According to Webster.edu,
“The final stage of Erikson’s (1982) theory is later adulthood (age 60 years and older). The crisis represented
by this last life stage is integrity versus despair. Erikson (1982) proposes that this stage begins when the
individual experiences a sense of mortality. This may be in response to retirement, the death of a spouse or
close friends, or may simply result from changing social roles. No matter what the cause, this sense of
mortality precipitates the final life crisis. The final life crisis manifests itself as a review of the individual1s
life-career” (Webster, 2010). With this information, I would conclude that he is in the despair because he
reflects on his life, stating, “I remember when I was your age, I used to be so optimistic with my life. Now I
am an old man.”
13. Religious affiliation &
significance. Explain.
He is a follower of Christ, stating that he is a Baptist and attends church regularly because it fills him with joy
14. Nutritional status,
Ht/Wt/BMI, who grocery
shops, what do they have in
the fridge/cupboards, who
cooks, describe typical
meals? Community
resources? Explain.
Nutritional status: He eats 3-4 small meals a day, mainly consisting of a type of carbohydrate and a meat.
and hope for the rest of his life.
One day he would eat toast and coffee for breakfast, left overs lunch and a personal pan pizza for supper, the
next day he would go out to eat for every meal. He really enjoys McDonald’s coffee as well as their
breakfast’s. He is 5’ 9” tall, and weighs 208 pounds. The U.S. National Institute of Health (2017) predicts his
BMI to be 30.7 which means he is obese. He states, “My girlfriend normally shops for me, I tell her what to
get and she drives to Walmart to get it.” His cupboards and fridge consist of a variety of different foods
including: Cereal, granola bars, chips, white milk, apples, coffee, bananas, potatoes, chicken and TV dinners.
He does not have any community resources set-up for him now, stating, “I don’t see the need right now.”
15. Preventive health,
immunizations, screenings,
and health promotion
activities.(include dates)
Fall.2017.njs©
Immunizations
Prevnar 13- Complete on 9/28/15.
Prevnar 23- Complete on 11/15/16.
Tdap- Complete on 4/28/17.
Zoster-N/A
Flu- Complete on 10/13/17.
Screenings
Depression- N/A
Colonoscopy-Completed
in 2015, with no new
findings.
Mammogram- N/A
Health Promotion
Alcohol- No alcohol consumption
Drug use- …
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