Head
How to conduct the assessment
The researcher performed a complete head-to-toe assessment on Mr. Joe, a 75-year old neighbor. The assessment of the head focused on the issue of shape and symmetry, the condition of his hair and scalp. The process involved physical assessment of the entire head.
Review of the system with normal and abnormal findings
This assessment did not involve any laboratory procedures. Given the advanced age of the patient, the focus was to determine any abnormalities in the hair and skin in this region. It was noted that the patient’s hair had grown thin and some had fallen off. The color of their hair was a completely grey. The grey color of the hair was considered normal given the age of the patient.
Analysis of age-specific risk reduction, health screen, and immunization
The weakening of the hair was associated to chemotherapy that the patient had undergone recently as part of his prostate cancer treatment. At the time of the assessment, he had completed his treatment and was cancer free. According to Gasper and Dillon (2011), there is no immunization against hair loss when one is subjected to chemotherapy.
Expectation of normal findings
The grey hair was an expected finding. However, their weak nature was considered abnormal, and an indication of underlying medical problem.
Differential diagnosis
Inasmuch as the condition was associated to the recent case of chemotherapy, differential diagnosis was considered to rule out the possibility of other medical problems that could have similar symptoms. Differential diagnosis for lupus, hyperthyroidism, or metal poisoning may have to be ruled out.
Plan of care
In case it is confirmed that the problem is caused by the impact of chemotherapy after the differential diagnosis, then the patient may be expected to maintain a well balanced diet. The nurse will also advise him to be physically active and to reduce excessive intake of sugar. The hair will be evaluated to determine the level of improvement.
Client and age-appropriate evidenced based practice strategies for health promotion
The client’s age is relatively advanced. At 75, it is common to start developing problems with the hair. To promote his health, age-appropriate strategies will be needed to keep him healthy and strong. The patient will need to maintain a balanced diet and regular exercise. He will also need to maintain high levels of hygiene in the hair and avoid handling it unless it is necessary.
Pharmacological treatments that can be used to address health issues for this client
The client may need pharmacological treatment to address his condition. The nurse recommends application of coconut oil at least twice a day, as Jarvis (2012) recommends.
Eyes
How to conduct the assessment
The assessment of the eye focused on physical examination of the conjunctiva, sclera, and eye pupils. The researcher investigated the patient’s ability to react to light and follow the figure. A simple reading test for each eye was also conducted.
Review of the system with normal and abnormal findings
A review of the eye revealed that the patient had good eyesight. There was no particular problem detected in the conjunctiva, sclera, and pupil. At 75 years, Mr. Joe’s eyes were in perfect health condition.
Analysis of age-specific risk reduction, health screen, and immunization
According to Cooper and Gosnell (2015), as people get to the advanced ages, they start developing eye problems. Regular health screening for problems such as cataract may be necessary to prevent total loss of eyesight. As at now, there is no specific immunization for eye problems among the elderly. However, maintaining healthy diet may be of help.
Expectation of normal findings
The age of the patient made the researcher believe that he might have problems passing the reading test. However, the test revealed that there were no abnormalities with his sight.
Differential diagnosis
Differential diagnosis would have been necessary if a problem or a given symptom was noticed in the eye. However, the patient’s eye condition was perfect, making it unnecessary to conduct any differential diagnosis.
Plan of care
The plan of care for this patient for his eyes will basically involve offering advice on how to maintain the good health through proper nutrition and avoiding exposure to chemicals and other substances that may harm the eyes.
Client and age-appropriate evidenced based practice strategies for health promotion
According to Henry, Stapleton, and Edgerly (2012), it is common to find a number of the elderly persons suffering from various eye problems. At his age, the most appropriate strategies of maintaining good conditions of his eye will be to avoid excessive intake of alcohol and exposure to dangerous chemicals
Pharmacological treatments that can be used to address health issues for this client
The patient will not need any pharmacological treatments of the eye because they are in good condition.
Ears
How to conduct the assessment
In this assessment, the researcher spoke in different tones, including a whisper, to determine the ability of the patient to hear sound in different frequencies. The researcher also spoke while hiding the lips to eliminates chances of the patient reading the lips to supplement any hearing problems. Finally the eye was physically examined to determine any damages or to the external parts of the ear.
Review of the system with normal and abnormal findings
The patient had excessive amounts of wax in the ear. He was straining to hear whenever the researcher spoke in low tones, especially when the lips were hidden limiting his ability to capture the words by reading the lips. A laboratory test would be necessary to further investigate causes of excessive amounts of wax in the ear. It was suspected that the patient could be suffering from presbycusis.
Analysis of age-specific risk reduction, health screen, and immunization
Beebe and Myers (2011) note that a number of elderly people are more susceptible to presbycusis. A laboratory screening would help in confirming this condition. This condition may be worsened if one if working in areas where there is excessive noise pollution. There is no immunization for this problem. However, risk reduction strategies involve staying away from areas where there is noise pollution.
Expectation of normal findings
It was expected that the patient would have normal hearing capacity. However, the abnormalities in the eye strongly suggested that the patient could be suffering from presbycusis. This was confirmed by his limited ability to hear low-frequency sounds.
Differential diagnosis
It will be necessary to conduct deferential diagnosis for Tinnitus. Some of the symptoms observed can also be witnessed among patients suffering from this disease.
Plan of care
After undergoing differential diagnosis to rule out the possibility of the patient suffering from tinnitus, a plan of care will be developed for the patient. The care plan will emphasize on the need to avoid noisy areas.
Client and age-appropriate evidenced based practice strategies for health promotion
The age of the client and his current ear condition demands that he embraces the use of assistive listening devices to improve the hearing capacity. Strict avoidance of all forms of noise will also be needed (McMann, 2013).
Pharmacological treatments that can be used to address health issues for this client
If the hearing problem is not adverse, then the patient will only need to use hearing devices to correct the condition. If this condition worsens, then cochlear implants may be recommended to correct the medical condition.
Thoracic Region
How to conduct the assessment
This assessment will involve investigating any abnormal sounds from the lungs or heart. The researcher will be keen to determine presence or lack of specific appropriate sound and their quality. Palpating the walls of the chest and the breasts for any lumps or abnormal tenderness was also conducted.
Review of the system with normal and abnormal findings
Cardiac and lung problems are some of the common problems affecting the elderly. However, it was observed that Mr. Joe’s heartbeat was normal. The sound from his chest showed no abnormalities in the lungs or heart.
Analysis of age-specific risk reduction, health screen, and immunization
At 75 years, Mr. Joe may need regular screening of the heart to ensure that he does not develop cardiac problems. There was no medical condition reported that would require immunization.
Expectation of normal findings
The patient was physically strong and it was expected that he would have normal heart and lung functioning. This was confirmed through the physical test. No abnormalities were identified through the test.
Differential diagnosis
Differential diagnosis will not be different in the case of Joe because there were no complications in his thoracic region.
Plan of care
Inasmuch as the heart and lungs of the patient are in perfect condition, he will still need a plan of care to maintain his good health. This will involve avoiding in-take of excessive calories. The patient will also be informed of the need to avoid constant dust and other air pollutants. Regular exercise may also be helpful in improving his condition.
Client and age-appropriate evidenced based practice strategies for health promotion
To promote good health for the patient based on his age, it will be necessary for him to maintain regular exercise to promote his thoracic health.
Pharmacological treatments that can be used to address health issues for this client
There will be no pharmacological treatments needed for this patient.
Foot problems
How to conduct the assessment
The researcher conducted a physical assessment of the foot to determine any abnormal swellings or weaknesses of the bone.
Review of the system with normal and abnormal findings
Foot swelling and weak bones are common problems among the elderly people. Mr. Joe did not have any abnormal swelling on his feet.
Analysis of age-specific risk reduction, health screen, and immunization
To reduce the risk of feet swelling, the client will need to keep physically fit by going to the gym regularly.
Expectation of normal findings
Based on the physical strength of the patient, it was expected that he would have no problems on his feet.
Differential diagnosis
Differential diagnosis was unnecessary because there were no problems detected on his feet.
Plan of care
The patient will need to maintain foot hygiene. This will need to be accompanied by regular outdoor exercises.
Client and age-appropriate evidenced based practice strategies for health promotion
To promote the health of the patient in regard to his feet, the researcher will inform him about ways of strengthening his bones and maintaining good hygiene of the foot.
Pharmacological treatments that can be used to address health issues for this client
Pharmacological treatment was not necessary because no medical problem was detected.
References
Beebe, R., & Myers, C. (2011). Paramedic Professional: Medical Emergencies, Maternal Health & Pediatric. vol. 2. Clifton Park: Delmar Pub.
Cooper, K., & Gosnell, K. (2015). Foundations and adult health nursing. St. Louis: Elsevier.
Gasper, M. L., & Dillon, P. M. (2011). Clinical Simulations for Nursing Education – Learner Volume. Philadelphia: F. A. Davis Company.
Henry, M. C., Stapleton, E. R., & Edgerly, D. (2012). EMT prehospital care. St. Louis, Mo: Mosby JEMS/Elsevier.
Jarvis, C. (2012). Physical examination & health assessment. St. Louis, Mo: Elsevier/Saunders.
McMann, J. (2013). Professional guide to assessment. Hoboken: Rittenhouse Book Distributors.