How to write a nursing Therapeutic assessment case study (Solved)

How to write a nursing Therapeutic assessment case study (Solved)

Assignment: Identify an older adult age 65 +, use a 1st and last initial. Execute a therapeutic assessment interview with them for at least two interview sessions assessing their self-identified: Name J. Harris 67 y.o. Female

Demographics, life time education and career/employment : Eastern North Carolina, High School Graduate,33 years County School Printer

Two most significant (positive) times in their lives:
1) Having kids
2) Buying First Home

What past hardship or loss has the client successfully negotiated in the past? Losing a job in Philadelphia and relocating to North Carolina for a better job with better benefits

Two personal strengths: Responsible and Resourceful

Engage them in identifying what is healthy versus non-healthy coping skills
non-healthy- worrying, lack of exercise

Inquire of 2 healthy coping skills they have used in the past and/or now- prayer and walking

Three (3) pieces of advice they would give to their younger self if they could?
1) Go to College
2) Wait on Marriage
3) Go to Military

Support the client in taking the Geriatric Depression Scale.pdf J. Harris scored 2 ,2 is considered normal
J. Harris has dropped many activities and interests. she perfers to stay home, rather than going out and doing new things

Support the client in taking the Fulmer SPICES Assessment.pdf J Harris able to sleep 8 hours/ night ,Able to eat with fork and spoon and swallow effectively with no weight loss, Patient was continent of bladder and stool during assessment,Patient was able to name President Biden, give todays date and year, and give birthdate, Pt was ambulatory without falls, No evidence of skin breakdown. Skin was elastic and non-tenting.

Read Mini Mental State Exam.pdf and Patient_Stress_Questionnaire.pdf Patient scored 30 points on MMSE which represents No cognitive impairment, Patient scored 7 on Stress Questionnaire, pt had several days of of trouble falling asleep ,feeling tired or having little energy,not being able to to stop or control worrying, worrying too much about different things,becoming easily annoyed or irritable, more than half days overeating, drink alcohol once a month 5 oz of wine

Read Hall, Hall, and Chapman Article.pdf

Report the findings from the Geriatric Depression Scale, Fulmer Spices, Patient Stress Questionnaire, and the Mini-Mental Status Exam

Discuss your older adult’s level of ego integrity vs. despair as described by psychoanalyst Erik Erikson. If you had to rate them on a scale of 1-10, with 1 representing a full state of despair and 10 representing full ego integrity, what rating would you give your older adult? J harris would rate a 7( explain why)

Describe at least two nursing diagnoses for this client.
Chronic pain
Activity intolerance
Create a plan of care for the client to include at least three nursing goals with two nursing interventions each.


Reporting Findings from Fulmer Spices

The client was supported in taking the Fulmer SPICES assessment. The assessment tool is commonly used in assessing senior patients (Li et al., 2021). The test is crucial in assessing how older individuals are coping with normal or pathological aging.  Normal aging results in various changes of multiple body systems. This may impact the ability of the individuals to engage in normal daily activities.  The changes are also responsible for various health needs and conditions. There is a high prevalence of various health-related conditions in older patients. These problems are skin breakdown, falls and fall-related injuries, confusion, incontinence, difficulty eating or feeding, and sleeping disorders.  Nurses and other healthcare practitioners should ensure these problems are addressed in patients to increase their health and wellbeing. The conditions can also be flagged for further assessment of the patient’s current health status.  The best tool for assessing these problems is the Fulmer SPICES tool.

The tool is an effective and efficient instrument that can be used to obtain information from the patient necessary to prevent the deterioration of health. SPICES is an acronym for common syndromes occurring in patients. S symbolizes sleep disorders, P symbolizes problems with feeding or eating, I symbolizes incontinence. C symbolizes confusion, E symbolizes the evidence of falls, and S symbolizes skin breakdown. So basically, the healthcare provider notes the evidence of sleep disorders, eating or feeding disorders, incontinence, confusion, falls, and skin breakdown. These are common marker conditions in senior individuals.

From the case, study the SPICES tool was used to assess the patient. The patient was able to sleep for eight hours a night. This is normal. Studies indicate that healthy individuals need between seven and nine hours of sleep per night. It is clear that the patient has no sleep disorder. The patient has no problems with eating and feeding. He can eat with a spoon and fork and swallow effectively with no weight loss. The patient has no incontinence. Urinary incontinence is common in geriatric patients. The patient was also not confused. He was oriented to time, place, and person. He was able to name the current American president, give his full name and death of birth and give the date. This indicates the patient has no problem with her cognition and memory. The patient had no evidence of falls. He was able to ambulate without falling. Finally, he had no evidence of skin breakdown. His skin was elastic and non-tenting.

Findings of Geriatric Depression Scale

The geriatric depression scale measures the level of depression in geriatric clients. Initially, the scale had thirty assessment criteria. It was reduced to a 15 item version. The items selected in the revised scale correlate with the depression diagnostic criteria according to the standard diagnostic criteria.  Out of the 15 items, a score of greater than 5 points suggests depression. A score of greater than ten points is always indicative of depression. Greater than five points using the scale warrants a follow-up and comprehensive assessment.  Harris has a score of 2. Since two is less than five, the patient has no depression.

Findings of Patient Stress Questionnaire and Mini-Mental State Exam.

A patient stress questionnaire helps in determining stress levels in the patient. However, the assessment tool is not designed for geriatric patients with various developmental disabilities.  The patient has a score of 7 on the patient stress questionnaire. This indicates that the patient had some level of stress. She had trouble falling asleep. Some of the stressors include feeling tired or having little energy, not stopping or controlling worrying, becoming easily annoyed, and over half days overeating. The patient also takes alcohol. All these stressors have a significant impact on the health and wellbeing of the patient. The Mini-Mental Status Exam indicates a score of 30. This shows that the patient has no cognitive impairment.

The Level of Ego Integrity vs. Despair

The Ego integrity is the eighth and final stage of the theory of psychosocial development by Erik Erikson. Since the patient is 67 years old, she belongs to this stage. On a scale of one to ten, with one representing a full state of despair and 10 representing a full state or f ego integrity, I will score the patient as 7. Looking back to their life, the patient has certain achievements he looks up to (Westerholf et al., 2017). The patient is happy about having kids and buying their house in their previous days. He sees having kids and buying their first home as his achievements. The patient has not reached a full state of ego integrity because he is not satisfied with certain aspects of his previous life. He states that he would advise her younger self to go to the military, waiting on marriage, and go to college. Possibly the patient is looking back to the failures in his life.

Nursing Diagnosis for the Client

Based on the history and physical assessments, various nursing diagnoses can be made. The first nursing diagnosis is chronic pain related to chronic psychological disability as evidenced by changes in sleep patterns, altered ability to continue normal activities, fatigue, and reduced social interaction. Chronic pain typically lasts for more than 12 months. Chronic pain has impacted various aspects of the patient’s life. Firstly the patient has dropped many activities and interests. He states that he prefers staying home rather than going out and doing new things. The other signs and symptoms that may indicate chronic psychological pain the patient is experiencing include trouble with falling asleep, excessive worry, aggression, and overeating.  The causes of chronic pain include side effects of treatments, injuring agents, disease process, chronic psychological disability, and chronic physical disability. In the patient, the potential causes of chronic pain include the disease process and chronic psychological disability.

The second nursing diagnosis is activity intolerance related to generalized weakness, lack of motivation, and imposed activity restriction, as evidenced by the patient reporting having little energy and trouble sleeping. Activity intolerance is described as insufficient psychological and physiological energy to supplement or support the desired or required daily activities (Konulacak, 2017). The activity intolerance has affected the lifestyle of the patient. Firstly, the patient has changed her physical exercise lifestyle.  He has also dropped many interests and activities. He states that he prefers staying at home rather than going out and trying new things. The trouble sleeping may interfere with the patient’s energy level. The excessive worry may also interfere with the ability of the patient to engage in certain daily activities.  Finally, the feeling of having little energy or being fatigued may also impair the patient’s ability to initiate or perform various activities in his life.

Plan of Care

Various interventions can be implemented to improve the health and wellbeing of the patient. The intervention will focus on the two nursing diagnoses.  The expected outcome of therapy will be to restore the ability of the patient to engage in regular activities healthily with no signs of activity intolerance. The expected outcome will be based on the patient’s ability to provide positive verbal feedback in response to his activity level.  The patient will be able to indicate effective energy management techniques. The patient will also perform their daily activity without loss of energy or exhaustion. Finally, the geriatric patient will not display respiratory and cardiovascular malfunction, especially when engaging in daily activities.

Various interventions can be implemented to restore the patient’s ability to engage in daily activities. J. Harris can be encouraged to be involved in physical activity by developing or engaging in a patient exercise program. Engaging in moderate activities and exercises will improve cardiovascular functioning. Exercising can prevent various health disorders.  It can also help strengthen the body muscles enabling the patient to engage in his daily activities (Konulacak, 2017). Other functions of exercising are improved coordination, improved balance, and improved mental and psychological wellbeing. Secondly, the patient can be encouraged to rest between exercises and activities.  This will ensure optimal performance during the sessions or activities. The patient should be helped in scheduling and planning his activities. This will motivate the patients to engage in various activities. The patient should be educated in diet and eating habits.  Diet is crucial in improving energy levels and improving the patient’s overall health. The patients can also be encouraged to develop good breathing habits to improve their cardiovascular functioning during activities. They should also be educated on various strategies that they can utilize to reduce stress. Excessive worrying may hamper the ability of the patient to engage in daily activities. Finally, the patient should be educated to recognize the signs and symptoms of overactivity. This may prevent the development of complications related to overexertion.

Chronic pain should also be managed. The goal of treatment will be focused on the patient demonstrating relaxation technique, patient reporting pain level less than three on a scale of 1-10, and patient engagement in daily activities without any increase in the level of pain. Various nursing interventions can be implemented to relieve psychological pain. Firstly the patient should be assisted in making decisions in choosing a particular strategy for pain management. This will increase their willingness to adapt the strategies. The need for the use of a pharmacological approach should be evaluated. Antidepressants such as lithium salts can manage anxiety and excessive worry. Analgesics such as opioids and non-opioid can be administered to relieve physical pain. The dose of the drugs should be adjusted to avoid dangerous adverse reactions and dependence on certain pain medications. Nonpharmacological pain management techniques can also be implemented to relieve pain. Examples of nonpharmacological pain management techniques include massage, imagery, aromatherapy, distraction, and heat and cold treatment (Baumbauer et al., 2016).  The various cognitive-behavioral approach can also be utilized to enable the patients to identify and manage certain triggers and behaviors that may worsen the pain. These strategies will restore the patient’s sense of control and increase their participation in their care. Finally, the patient can also be advised on improving his interpersonal relationship as family support may be necessary for managing chronic pain.


Baumbauer, K. M., Young, E. E., Starkweather, A. R., Guite, J. W., Russell, B. S., & Manworren, R. C. (2016). Managing chronic pain in special populations with an emphasis on pediatric, geriatric, and drug abuser populations. Medical Clinics100(1), 183-197.

Konulacak, A. İ. D. B. (2017). Is Activity Intolerance One of The Nursing Diagnosis for Patients with Depression? Journal of Psychiatric Nursing8(2), 127-128.

Li, D., Sun, C. L., Kim, H., Soto-Perez-de-Celis, E., Chung, V., Koczywas, M., & Dale, W. (2021). Geriatric assessment-driven intervention (GAIN) on chemotherapy-related toxic effects in older adults with cancer: a randomized clinical trial. JAMA oncology7(11), e214158-e214158.

Westerhof, G. J., Bohlmeijer, E. T., & McAdams, D. P. (2017). The relation of ego integrity and despair to personality traits and mental health. The Journals of Gerontology: Series B72(3), 400-407.

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