Health History of an Elderly Person Using Gordons Functional Model - Case Study Example

ASSESSMENT OF THE HEALTH HISTORY OF AN ELDERLY PERSON USING GORDON’S FUNCTIONAL ASSESSMENT MODEL SUBMITTED BY: INTRODUCTION As humans age, the body goes through several changes. Elderly people are also more prone to diseases and falls due to the various age related changes. The elderly constitute a major portion of all the people who receive nursing care. The health of elderly people depends on several factors. The health problems of older people are exacerbated by the increased risk of illness associated with old age and the normal changes of aging. Several old people are not even aware that a problem exists until the symptoms get worse. It is important for geriatric nurses to ensure that these patients receive optimum care. It is necessary for them to understand and incorporate into daily practice valid and reliable tools to assess the functional, physical, cognitive, psychological, social and spiritual status of older adults. This case study is aimed at demonstrating an understanding of the application of the theoretical components of the health history based on Gordon’s functional assessment model and where applicable, the assessment process and analyzing obtained data in order to draw meaningful conclusions. Specific objectives include the following: Undertake a health history of an elderly person (70-85) from the community Synthesize and analyze the health history data obtained at interview(s) focusing the analysis on the following points: the case study participant’s perspectives or issues of importance to him/her regarding health or illness developmental, cultural and social, and spiritual factors that impact on your participant coping mechanisms in health or illness identification of any health assessment techniques that would be appropriate, including the rationale for the choice of techniques Identification of any health promotion measures that are appropriate to the participant The following is the data obtained during two interviews. Informed consent was obtained from the patient prior to the interview. Questions asked during the interview were based on Gordon’s parameters. A list of questions was made corresponding to all 11 parameters. (Gordon, 1994, 2000) NURSING HEALTH HISTORY A. BIOGRAPHIC DATA Name: Patient XY Address: Height: 5’8” Weight: 80 kg Age: 70 years old Sex: Male Civil Status: Married Nationality: Indian Religion: Roman Catholic B. PAST MEDICAL HISTORY A. Previous hospitalization 2004-Cataract operation of right eye 2007-Severe breathlessness 2007-Operation for fissures 2009-Cataract operation of left eye B. Injuries/ Accident No major injuries C. SOCIO-ECONOMIC HISTORY XY started working at the age of 17 years and being the eldest among his siblings, assumed the role of the family breadwinner after his father’s death. He worked in a chemical factory for 15 years. As a result of the factory closing down, then joined his father-in-law in the construction business. He was unaware of the health risks associated with the exposure to dust and other chemicals at construction sites and never took any precautions to minimize exposure. D. ENVIRONMENTAL HISTORY Mr. XY is particularly sensitive to air pollution due to his COPD. Due to the diminished vision in the right eye, he has to ensure that he moves around carefully. E. GORDON’S FUNCTIONAL HEALTH PATTERNS Pattern of Health Perception and Health Management: Mr. XY describes his general health as being stable. He does not go for any regular checkups. He has never suffered from any major illnesses. Recently, his hands have started to tremble sometimes making it difficult for him to grasp things. He assumes that it is the onset of Parkinson’s disease but hasn’t yet sought the opinion of a neurologist or any health practitioner in this regard. Patient X is aware that the trembling will eventually worsen and need medical attention. He admitted that he doesn’t like visiting doctors and taking medication; hence, he has refrained from visiting the specialist for the trembling. He is very religious and believes that it is God and not the doctor who will take care of him. Mr. XY has hypertension and takes medication for this. He believes that the hypertension was caused by stress, as no one in his family had a history of hypertension. He has never visited a cardiologist and the medication for hypertension was prescribed by his family physician. Mr. XY discovered that he had COPD only after a major breathlessness attack that he had in 2007. He has been consulting a pulmonary specialist only since then. He has had a persistent cough for a very long time but never bothered to see a specialist. He also thinks that visits to doctors are expensive and goes only when the symptoms have worsened and there is no alternative. Mr. XY’s medication comprises his hypertension medication. He travels with his bronchodilator everywhere. He tends to self medicate if he experiences symptoms similar to those he has experienced before. He remembers medicines that have been previously prescribed and tends to take the same medication when he develops similar symptoms. He has never smoked and consumes alcohol only on social occasions. Nutritional-Metabolic Pattern: Mr. XY avoids spicy food after his fissure surgery. His food comprises rice, fish, vegetables, and meat. He prefers vegetarian food but because non-vegetarian food is predominant in the family, his diet is mainly a meat diet. He is also very fond of sweets. Breakfast comprises a glass of milk along with 4 slices of bread and butter or jam or eggs/bacon/ham. Lunch typically comprises rice and fish/meat curry. Dinner comprises bread and meat/fish curry and/or vegetables. Fluid intake comprises about 5-6 glasses of water in a day. Mr. XY has had a steady weight of around 80 kgs for the last ten years. He tends to suffer from acidity and indigestion sometimes and always has an antacid. Skin appears dry but otherwise healthy. No incidence of burning or skin itching was noted. No coldness or temperature inequalities between the extremities were noted. Mr. XY had two of his molars removed 2 years ago and had 3 cavities filled. His BMI was computed to be 26.76. The International Classification of adult underweight, overweight and obesity according to BMI Classification BMI(kg/m�) Principal cut-off points Additional cut-off points Underweight Read More