Case Study For The Clinic Assessment Assignment Paper

Case Study For The Clinic Assessment Assignment Paper

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Assignment-Case Study

Clinical interviews enable healthcare professionals to acquire essential health-related information. This data guide them in making significant clinical decisions, including making diagnosis and developing an appropriate treatment plan. Therefore, clinical assessment is the backbone of quality patient care and positive health outcomes. This paper presents an assessment and plan of care based on information acquired during the home visit; the CGA parts to be completed next for Homer; questions to be asked to Homer and his daughter; and additional tasks to be performed Case Study For The Clinic Assessment Assignment Paper.

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Assessment

Homer’s first diagnosis is stage-1 high blood pressure. According to Tocci et al. (2019), systolic pressure, ranging from 140 to 159, or diastolic pressure between 90 and 99 characterizes stage-1 high blood pressure. Therefore, the homer has stage-1 high blood pressure since his blood pressure during the visit is BP 152/68. Secondly, homer is diagnosed with insomnia. This sleep disorder is characterized by difficulty falling asleep and remaining asleep at night or waking up at night, or waking up too early the following morning (Patel et al., 2018)Case Study For The Clinic Assessment Assignment Paper. People with insomnia do not feel well-rested the following day and experience daytime sleepiness or tiredness (Abad & Guilleminault, 2018). These individuals also experience difficulty focusing on tasks, paying attention, or remembering. During the clinical assessment, homer reports waking two or three times at night. He further reports being a little tired the following morning. Therefore, insomnia qualifies as a potential diagnosis for the homer.

Another potential diagnosis health issue for the home is malnutrition. In elderly adults, malnutrition is caused by a lack of essential food components in the diet (Αntoniadou & Varzakas, 2021). During the clinic assessment, homer denies taking a balanced diet. Instead, he takes sandwiches for lunch, soup, or cereals. Other symptoms of malnutrition include reduced appetite, losing interest in food and drink, and feeling tired. The client reports feeling tired during day time and denies feeling hungry. The last potential diagnosis for the homer is depression. In elderly adults, major depressive disorder is a common psychological issue, which is characterized by unintentional weight loss in older adults, reduced appetite, fatigue, and insomnia (Kim et al., 2021). The client has lost weight since the previous visit. He further reports reduced appetite, waking up two to three times at night, and feeling tired, qualifying for a depression diagnosis. Nonetheless, major depressive disorder is ruled out since the client does not report mood swings or loss of interest in pleasurable activities, which are a requirement for depression diagnosis based on the DSMV diagnostic criteria (Hasin et al., 2018)Case Study For The Clinic Assessment Assignment Paper.

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The Plan of Care

The plan of care aims at addressing homer’s current diagnosis, including stage-1 high blood pressure, insomnia, and malnutrition. First, stage-1 high blood pressure will be managed through medication and lifestyle behavior modifications. The homer was prescribed low-dose thiazide diuretics. According to Flack and Adekola (2020), a low-dose thiazide diuretic is the first-line treatment for stage-1 high blood pressure in elderly adults. On the other hand, non-medication treatment for this client includes taking a heart-healthy diet with limited salt; engaging in physical activities regularly; and sleeping for 7 to 9 hours daily. Secondly, insomnia will be managed through medication and encouraging the client to practice sleep hygiene such as exercising during the day and switching off lights at night. The client should be prescribed suvorexant, which is the FDA-approved treatment for insomnia in elderly adults (Abad & Guilleminault, 2018)Case Study For The Clinic Assessment Assignment Paper. Combining this medication with sleep hygiene would improve homer’s sleep quality and duration. Lastly, a meal plan should be prepared to improve the client’s feeding habits. The meal plan will consist of three main meals and two snacks. Every meal should consist of all food components in their appropriate proportions to meet his nutritional requirements and prevent weight loss. Additionally, the homer will be encouraged to keep an alarm, which will remind him to take his meals on time.

Activities to be completed during the next Homer

The CGA parts to be completed next for Homer involves screening various chronic illnesses, including diabetes type 2 Mellitus, cardiovascular diseases, and different cancer forms. Screening is recommended since early detection and treatment will reduce the likelihood of developing various preventable health illnesses. Homer and his daughter will be asked the following questions during the next visit  Case Study For The Clinic Assessment Assignment Paper

1. How many hours do you sleep in 24 hours?
2. Do you still feel tired during the day?

• Has your appetite improved?

1. Do you adhere to the meal plan?
2. Do you adhere to the medication regimen?

Additional tasks to be performed during the visit include taking homer’s vitals specifically blood pressure and weight to determine the efficacy of the plan of care.

Summary

The client is diagnosed with stage-1 high blood pressure, insomnia, and malnutrition. Stage-1 high blood pressure diagnosis has been informed by his current blood pressure, 152/68. The condition was managed through medication and lifestyle modifications. The homer was prescribed a low-dose thiazide diuretic and advised to take a healthy diet with less salt and exercise regularly. Homer’s second diagnosis is insomnia, which was based on waking up at night and feeling tired the following morning. This condition was managed by prescribing the homer suvorexant and encouraging the client to practice sleep hygiene such as exercising during the day and switching off lights at night. These interventions would improve his sleep quality and duration. The homer’s last diagnosis is malnutrition, which was informed by excess weight loss, reduced appetite, and poor feeding habits. This condition was addressed by developing a meal plan for the homer and encouraging him to follow it strictly. The efficacy of the plan of care would be determined through the client’s progress during the next visit. In the event of an improvement in weight and blood pressure, the client will be advised to continue with the current treatment therapy. However, an alternative plan will be developed if no improvement is noted during the visit Case Study For The Clinic Assessment Assignment Paper.

References

Abad, V. C., & Guilleminault, C. (2018). Insomnia in elderly patients: Recommendations for pharmacological management. Drugs & aging, 35, 791-817.

Flack, J. M., & Adekola, B. (2020). Blood pressure and the new ACC/AHA hypertension guidelines. Trends in cardiovascular medicine, 30(3), 160-164.

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA psychiatry, 75(4), 336-346.

Kim, Y., Kim, K., Chartier, K. G., Wike, T. L., & McDonald, S. E. (2021). Adverse childhood experience patterns, major depressive disorder, and substance use disorder in older adults. Aging & Mental Health, 25(3), 484-491.

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: a review. Journal of Clinical Sleep Medicine, 14(6), 1017-1024.

Tocci, G., Presta, V., Figliuzzi, I., Miceli, F., Citoni, B., Coluccia, R., … & Volpe, M. (2019). Reclassification of hypertensive outpatients according to new US guidelines on high blood pressure. American Journal of Hypertension, 32(1), 77-87.

Αntoniadou, M., & Varzakas, T. (2021). Breaking the vicious circle of diet, malnutrition and oral health for the independent elderly. Critical Reviews in Food Science and Nutrition, 61(19), 3233-3255. Case Study For The Clinic Assessment Assignment Paper

Visit with Homer

Two months have passed since Homer’s second visit. Watch his latest visit:

CGA Third Visit

This Week’s Assignment

Identify what your assessment and plan of care would be for Homer at this visit. Indicate what parts of the CGA you would complete next for Homer. What questions would you ask Homer and his daughter, and what additional tasks would you perform? Provide a rationale for all decisions, and include references per APA 7^th edition.

Use the Comprehensive Geriatric Assessment (CGA) Outline to prepare your assignment based on this week’s visit with Homer. Use each of the headings listed in the outline in your document. Your assignment should be written using APA 7^th edition and include references. To view the rubric for this assignment, please go to My Grades in your course menu. Locate the assignment in the list and select View Rubric. Case Study For The Clinic Assessment Assignment Paper

Name: CGA Rubric Weeks 2 – 6

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Name:CGA Rubric Weeks 2 – 6

Nurse: Well, Mr. Grant, it’s been a while since your last visit. How have you been getting along? You look a little thinner from your last visit. I noticed that you’re not wearing your dentures.

1. GRANT: I’ve been getting along pretty well. Julie says I’m too thin. I’m not hungry much these days. My dentures don’t fit so well.

Julie: Yeah, dad has lost some weight since his last visit. His clothes are a little baggy. He is not eating like he should.

Nurse: Tell me, Mr. Grant, do you cook for yourself? What do you usually eat during the day? Do you make breakfast? What do you eat for lunch and dinner?

1. GRANT: My wife did all the cooking. I never had to lift a finger. She didn’t want me near the kitchen anyways. I’m a bad cook when I try. Most days, I fix myself a sandwich for lunch.

Julie: One of us brings dad over on Sundays for dinner. I prepare extra meals for him and put them in the refrigerator for him to eat during the week. Most of the time the leftovers are still there when I visit him during the week.

Nurse: Mr. Grant. Have you been eating regular meals?

1. GRANT: I heat up a can of soup in the microwave. Or sometimes, I eat a bowl of cereal.

Julie: Dad, I keep telling you to heat up the food I leave you. You know how to use the microwave.

1. GRANT: I just forget. It’s easier to make a sandwich or eat some cereal.

Julie: You know, dad still lives home alone. I’m worried about him being there at night. I don’t know if he’s wandering around at night. I’m afraid he might trip and fall.

Nurse: Do you wake up during the night, Mr Grant?

1. GRANT: Maybe two or three times.

Nurse: And how do you feel in the morning when you’re awake for the day?

1. GRANT: I’m a little tired. Sometimes, I might take a nap, you know, rest my eyes.
   

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Julie: Well, dad, you do seem to get more tired during the day than you used to.

Nurse: OK, Mr Grant, let’s proceed with our examination.

Review the Information gathered at Homer’s physical.

• VS – BP 152/68; AP 68 and irreg. Lung sounds diminished lower lobes – O2 sats 95%
• Previous visit: VS – BP 154/72; AP – 88; O2 sats 95% Lung sounds diminished in lower lobes.
• Weight: 144 lbs. (BMI 21.9); Previous visit: Weight – 150 lbs.

Follow-up

I’d like to see you again in two months for a follow up Case Study For The Clinic Assessment Assignment Paper