The Holistic Patient Assessment

Part 1: The holistic health assessment of a 72-year-old woman who is my grandmother

  1. Health History

In her early life just before she hit the age of 55, my grandmother led a very healthy life where she did not have any significant health issues that required her to be taken to the hospital for prolonged treatment or major medical surgeries or procedures. However, she started getting minor and sometimes major medical issues as she reached the age of 60. She was diagnosed with diabetes at the age of 59. Currently, she is being treated for several Respiratory Diseases such as pneumonia. At the age of 69, she fell and broke a leg, and even though the leg was treated successfully, she uses a wheelchair or a walking stick when she is moving from one place to another.

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  1. Physiological Assessment

I conducted a physiological test on my grandmother and I can state that she seems healthy. Her heart and nervous system function normally for a 72-year-old woman. However, it is essential to mention that she was diagnosed with a heart condition at the age of 66 and it was treated successfully.

  1. Psychological Assessment

A holistic health assessment must have a psychological assessment section that seeks to determine the psychological stability of an individual (Crouch & Meurier, 2011). One of the significant issues I noticed with my grandmother is that she usually has anxiety attacks, depressions, and panic attacks from time to time. However, I have also noticed that her mind is functioning well, and she has perfect memory. She knows what is happening around her and apart from having trouble remembering the names of relatives she has not seen recently, she is of sound mind.

  1. Social Assessment

In her younger age, my grandmother was a very social person and she had many friends. However, many of her friends have died and what she has is her family. All her children and grandchildren are either working or at school, and they do not have enough time in their hands to spend time with her. She is a lonely woman and most times, she is despondent. Her husband died six years ago, and that was her only faithful companion.  

  1. Cultural Assessment

A cultural assessment is done to determine if the patient cultural values and hoe they live their livest (Crouch & Meurier, 2011). My grandmother is a strong Christian, and she holds that she should be in ways that do not offend her Christian values. 

Developmental Assessment

As she grows older, she will face numerous psychosocial and cognitive developments, and this may negatively affect her general health. For example, as she grows older, she may start to forget to take her medication, which may make her health deteriorate even further.

  1. Spiritual Assessment

As stated earlier, my grandmother is very religious, and she professes the Christian faith. All doctors and nurses attending to her should understand this fact and always ensure that no procedures done to her contravene the Christian faith in any way (Wong & Chung, 2006). 

Part 2: Interpret the findings in your holistic health assessment data according to pathophysiologic disease states.

  1. An explanation of my grandmother’s heart condition

One of the conditions that have been identified above as affecting my grandmother is a heart condition. Even though her heart is working fine now, she got a heart attack a few years, which weakened her heart considerably making it hard for it to work optimally. Heart diseases have been identified as one of the leading causes of death in older women. High cholesterol and high blood pressure lead to high chances of heart attacks and strokes happening, and for this reason, older women should make sure that they maintain their blood pressure and cholesterol levels at all times (Wong & Chung, 2006). One should also ensure that they maintain a good and healthy diet at all times. This diet should be low in saturated fat and sodium. They should also reduce the consumption of alcohol to about only one bottle a day and avoid smoking at all costs. She has also been identified as having diabetes (Wong & Chung, 2006).

  1. How this condition impacts on her life 

Being 72 year old and having a heart condition is very hard, as it negatively impacts on the elderly patient. Firstly, she cannot exert her body for an extended amount of time. For instance, she cannot walk long distances or even go up and down stairs for several times. That is why she uses a wheelchair to help with mobility. She is always suffering from shortness of breath, which is known as dyspnea when she exerts herself. In many occasions, she is fatigued and weak in her body, making it hard to do anything. This is also heightened by the fact that she has diabetes. She also has some swelling in her legs, feet, and ankles. This condition is known as edema

  1. Discuss the client’s stress and coping mechanisms 

There is no doubt that my grandmother is grappling with stress and on some occasions, depression that is harming her life and health in general. The fact that she is all alone at home and sees her family on minimal occasions is one of the main reasons she has been battling psychological problems. It is vital to mention that when she lost her husband is when she started suffering from anxiety and depression. In addition, because her diabetes has been causing some pains in her body, as well as losing some of her senses such as eyesight, this has also been identified as a significant concern for her and this has led to the anxiety. 

Her coping mechanism has not been one of the best. To forget about her problem, she indulges in alcohol, which does not help her overall health since she has heart issues, as well as diabetes. She needs to have proper intervention methods that can help her cope with her situation, as well as help improve her physical health.

Part 3: Create a teaching plan that addresses the client holistically by applying the assessment data you have analyzed. 

  • Physical

Due to her weak heart and diabetes, my grandmother should start taking food with low cholesterol and sodium. This means that her foods should be fat-free and without any table salt. This will be difficult for her, but she should be encouraged to follow the diet. The teaching plan will involve letting her know that she should also not take alcohol or smoke, as this can affect her health adversely (Williams & Jones, 2006). To ensure this is successful, there should be no alcohol in the house at all. 

  • Psychological

She is suffering from anxiety, depressions, and panic attacks. The teaching plan should be to involve all family members and ensure that they work to minimize the triggers of these psychological issues such as loneliness. As a family, we can start spending time together, and she can start taking medication of depression and anxiety. 

  • Social

The teaching plan here will involve both my grandmother and our family. Since most of her friends have either died or moved on with their lives, I would encourage many of my family members to be dedicating a day or two in a week to come and spend time with our grandmother. This will help her fill the void of loneliness. We can also decide to take her in a home for the elderly where professional healthcare workers and other older adults whom they can start spending their time talking and sharing issues will surround her (Williams & Jones, 2006). This would help in filing the social void.  

  • Cultural

Her cultural beliefs are reasonable in the American system, and there will be no need to come up with goals or plans that are supposed to change them to suit her care.

  • Developmental

My grandmother’s psychosocial and cognitive development might have an impact on her overall health. For example, if her depression and other mental issues continue to deteriorate, then her overall health status will become worse. For this reason, it will be imperative to ensure that her psychological issues are dealt with, as this is going to give her an excellent opportunity to have a good life (Williams & Jones, 2006). 

  • Spiritual

My grandmother has been an influential Christian all her life and going to church every Sunday has been one of her most observed rituals. To encourage her to continue with this ritual, we have decided as a family that every Sunday, one of us will be accompanying our grandmother to church to make sure that she nourishes her spiritual needs in her life.

References

Crouch, A., & Meurier, C. (2011). Health Assessment. Chicago, IL: John Wiley & Sons

Williams, A., & Jones, M. (2006). Patients’ assessments of consulting a nurse practitioner: The

time factor. i 53(2), 188–195.

Wong F. K. Y., & Chung L. C. Y. (2006). Establishing a definition for a nurse‐led clinic:Structure, process, and outcome. Journal of Advanced Nursing, 53(3), 358–369.

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