Interview Portion of the Assessment

Please post a substantive post. Discussion: Post #1

J.P. is a 75-year-old retired factory worker being seen in the home setting for a yearly health assessment provided by his insurance company.

Subjective Data
No complaints at this time
Enrolled in Silver Sneakers
Eats out much of the time
Widowed
Has one daughter who lives in another state
Retired automotive parts factory worker
Drives to and from activities

Objective Data
Vital signs: T 37 P 80 R 18 BP 140/68
Weight: 200
HT: 5 feet, 6 inches

Questions

1. How should the nurse proceed with the interview portion of the assessment?
2. What are the components necessary to complete the interview?
3. Develop a problem list for subjective findings.
4. Develop a problem list for objective findings.
5. What teaching should the nurse consider from the problems list?
6. What interventions might be included in the plan of care for this patient?

The nurse should proceed with the interview portion of the assessment by conducting a thorough and patient-centered assessment to gather additional information about J.P.’s health and lifestyle. This interview should focus on his subjective data, which includes his personal and health-related information. Here’s how the nurse can approach the interview:

1. Establish Rapport: Begin by introducing themselves, building rapport, and creating a comfortable environment for J.P. to share information.
2. Open-Ended Questions: Use open-ended questions to encourage J.P. to talk about his overall health, concerns, and any changes he may have noticed since the last assessment.
3. Lifestyle and Habits: Ask about his daily routine, including diet, exercise, and any recreational activities like Silver Sneakers. Explore his eating habits in more detail, including the types of food he eats when dining out.
4. Family and Support: Inquire about his family situation, particularly his daughter who lives in another state. Assess the level of support he receives from his daughter and any other sources.
5. Medical History: Gather information about his medical history, including any chronic conditions, previous surgeries, allergies, and current medications. Ask about his experience with any recent illnesses or hospitalizations.
6. Medication Adherence: Check his understanding of his medications and adherence to prescribed treatment plans.
7. Functional Status: Assess his ability to perform activities of daily living (ADLs) and any mobility issues, especially since he’s a retired factory worker.
8. Safety: Inquire about his driving habits, vision, and any concerns related to safety, given his age.
9. Emotional Well-being: Explore his emotional health, including any signs of depression or anxiety related to being widowed and living alone.
10. Future Plans: Discuss his future plans and goals for maintaining his health and well-being.

Problem List for Subjective Findings:

1. Isolation due to being widowed and having a daughter living in another state.
2. Potential dietary issues related to frequently eating out.
3. Emotional well-being concerns, including potential depression or loneliness.
4. Medication adherence and understanding.

Problem List for Objective Findings:

1. Elevated blood pressure (140/68), which may require monitoring and potential intervention.
2. Overweight (BMI may be calculated based on height and weight).
3. Age-related considerations regarding driving safety.
4. Potential mobility issues related to age and past employment in a factory.

Teaching Considerations:

1. Nutrition: Education on making healthier choices while eating out and maintaining a balanced diet.
2. Medication Management: Ensure J.P. understands the purpose and proper administration of his medications.
3. Blood Pressure Management: Discuss the importance of blood pressure control through lifestyle modifications and medication adherence.
4. Emotional Support: Encourage him to seek social support and consider involvement in community activities or support groups.

Interventions in the Plan of Care:

1. Monitor blood pressure regularly and consult with a healthcare provider for appropriate management.
2. Collaborate with a dietitian to develop a personalized dietary plan.
3. Provide resources for local senior centers, social groups, or support networks to combat loneliness.
4. Encourage regular physical activity, considering Silver Sneakers or other suitable options.
5. Arrange for vision screening and evaluate his fitness for continued driving.
6. Ensure understanding of medication regimen and provide pill organizers if necessary.
7. Promote regular follow-up visits and screenings to monitor his health status.