Full Answer Section

• Balancing Patient Autonomy with Safety: There was a delicate situation with a patient who, despite mild cognitive impairment, insisted on continuing to drive against the family’s wishes. Navigating this conversation, respecting his autonomy while considering safety for him and others, was incredibly challenging and required a lot of tact and collaborative communication with the family and preceptor.

Successes:

• Improved Assessment Flow: I felt much more confident in conducting comprehensive geriatric assessments this week. My ability to transition smoothly between subjective and objective data collection, incorporating elements of functional assessment (ADLs/IADLs) and cognitive screening (e.g., MoCA, though not always formal) into the routine, improved significantly.
• Building Rapport: I had a few moments where I truly felt I connected with patients. One patient, initially hesitant to discuss her recent grief, opened up after I spent extra time listening to her story. These small successes in building trust are incredibly rewarding and reinforce the patient-centered aspect of advanced practice nursing.
• Identifying Potential Issues Early: In one case, while reviewing a patient’s medication list, I flagged a potential anticholinergic burden that was contributing to their reported constipation and dry mouth. My preceptor confirmed the concern, and we discussed a plan for medication adjustment. This felt like a real win, where my expanding knowledge directly benefited a patient.

Patient Assessment Example

Patient Presentation:

A 78-year-old female, Mrs. Adhiambo, presented to the clinic with her daughter, complaining of increasing fatigue, generalized weakness, and “not feeling quite right” over the past month. Her daughter reports Mrs. Adhiambo has been spending more time sleeping, has less interest in her usual activities (gardening, attending church group), and seems a bit “slower” to respond. Mrs. Adhiambo denies pain, fever, cough, dysuria, or any specific symptoms. Her appetite is slightly reduced, and she has had occasional mild constipation. She lives independently but relies on her daughter for errands.

Signs and Symptoms (S&S):

• Subjective:
  • Increasing fatigue (1 month duration)
  • Generalized weakness
  • “Not feeling quite right”
  • Increased sleep duration
  • Reduced interest in hobbies (gardening, church)
  • Slower responses (daughter’s observation)
  • Slightly reduced appetite
  • Occasional mild constipation
  • Denies specific organ system complaints (pain, fever, cough, dysuria)
• Objective:
  • Vitals: BP 130/70, HR 68, RR 16, Temp 36.6°C, SpO2 96% on room air. (All within normal limits, though a slightly lower BP than typical baseline for her).
  • General: Appears tired, responds slowly to questions, but oriented to person, place, and time. No acute distress. Well-groomed.
  • HEENT: Pale conjunctiva (noted during exam), dry mucous membranes (mild). No obvious signs of infection or inflammation.
  • Cardiac: Regular S1S2, no murmurs, rubs, or gallops.
  • Pulmonary: Clear to auscultation bilaterally, no adventitious sounds.
  • Abdominal: Soft, non-tender, non-distended, normoactive bowel sounds. No organomegaly.
  • Neurological: Cranial nerves intact. Motor strength 4/5 globally (reduced from 5/5 at last visit). Sensation intact. Reflexes 2+ symmetrical. Gait appears slightly unsteady but ambulates independently with a cane.
  • Skin: Poor skin turgor. No rashes or lesions.
  • Functional Assessment: Daughter reports some difficulty with IADLs (e.g., managing medications, meal preparation), consistent with her subjective fatigue and weakness. ADLs currently independent.
  • Cognitive Screen (informal): Unable to fully complete serial sevens and took longer to recall three words after 5 minutes. Suggests potential mild cognitive changes.

Assessment:

Mrs. Adhiambo, a 78-year-old female with a history of hypertension and osteoarthritis, presents with a 1-month history of progressive fatigue, generalized weakness, and reduced interest in activities. Her daughter notes slowed responses and increased sleep. Objective findings include mild pallor, dry mucous membranes, reduced strength, and possible mild cognitive changes. Her non-specific presentation suggests an underlying systemic process.

Differential Diagnoses with Rationales:

1. Anemia (e.g., Iron Deficiency Anemia, Anemia of Chronic Disease):
   • Rationale: Fatigue, generalized weakness, pallor of conjunctiva, and potentially reduced appetite are classic symptoms of anemia. Chronic inflammation (from osteoarthritis) or subtle gastrointestinal bleeding (constipation could be a contributing factor, though not specifically stated as a bleeding source) can lead to anemia in older adults. Anemia of chronic disease is common in the elderly with co-morbidities. This is a very common cause of non-specific decline in the elderly.
2. Depression (Late-Life Depression):
   • Rationale: Fatigue, increased sleep, loss of interest in hobbies (anhedonia), and generalized weakness are common symptoms of depression in older adults. Depression in the elderly often presents with somatic complaints rather than overt sadness. The “not feeling quite right” and slowed responses could also point to a depressive episode.
3. Dehydration/Electrolyte Imbalance (e.g., Hyponatremia):
   • Rationale: The dry mucous membranes and poor skin turgor suggest mild dehydration. Reduced appetite and potential for less fluid intake could contribute. Electrolyte imbalances, particularly hyponatremia (low sodium), are common in the elderly and can cause non-specific symptoms like fatigue, weakness, confusion, and falls. This could also explain the “slower responses.”
4. Hypothyroidism:
   • Rationale: Although less likely than the top three, hypothyroidism can cause fatigue, weakness, constipation, and slowed mentation, which align with Mrs. Adhiambo’s symptoms. It’s a common condition in older adults and should be screened for.
5. Undiagnosed or Worsening Chronic Disease:
   • Rationale: This broad category could include worsening heart failure (though no specific cardiac S&S), renal insufficiency, or even a slow-growing malignancy (though no red flags like weight loss or specific pain). This is why a comprehensive workup is needed.

Plan of Care:

1. Diagnostics:
   • Laboratory Tests:
     • Complete Blood Count (CBC): To confirm anemia and differentiate types (e.g., microcytic for iron deficiency).
     • Complete Metabolic Panel (CMP): To assess electrolytes, renal function, liver function, and glucose. Crucial for detecting dehydration or electrolyte imbalances.
     • Thyroid Stimulating Hormone (TSH): To screen for hypothyroidism.
     • Vitamin B12 and Folate levels: To rule out megaloblastic anemia, another common cause of fatigue/weakness in the elderly.
     • Urinalysis (UA) with Culture & Sensitivity (C&S): To rule out asymptomatic UTI, which can present atypically in the elderly.
     • Fecal Occult Blood Test (FOBT): To screen for occult GI bleeding, a cause of iron deficiency anemia.
2. Pharmacological Interventions (Pending Labs):
   • Address Dehydration (if confirmed): Encourage oral fluid intake. If severe and labs confirm significant dehydration/electrolyte imbalance, consider IV fluids if clinic capability or referral to ED.
   • Review Current Medications: Conduct a comprehensive medication reconciliation to identify any drugs contributing to fatigue, weakness, or constipation (e.g., anticholinergics, sedatives). Consider de-prescribing if appropriate once full picture is available.
3. Non-Pharmacological Interventions:
   • Nutrition Review: Advise on maintaining adequate hydration and balanced nutrition. Suggest easily digestible foods if appetite is low.
   • Activity: Encourage gentle daily activity as tolerated to prevent deconditioning, but emphasize rest periods.
   • Cognitive Engagement: Encourage continuation of mentally stimulating activities within her limits.
4. Follow-up:
   • Schedule a follow-up visit in 3-5 days for lab review and symptom re-evaluation.
   • Educate patient and daughter on “red flag” symptoms warranting immediate presentation to ER (e.g., severe confusion, falls, fever, severe shortness of breath, chest pain).
5. Referrals:
   • If anemia confirmed and cause unclear, consider Hematology consult.
   • If depression confirmed, consider Mental Health/Psychiatry for specialized evaluation and management.
   • If significant cognitive decline identified, consider Neurology or Geriatrician for formal cognitive assessment.

Health Promotion Intervention for this Patient

Given Mrs. Adhiambo’s age, baseline COPD (even if not currently exacerbating), and current non-specific symptoms pointing to a general decline, a key health promotion intervention would be Fall Prevention and Home Safety Assessment.

• Rationale: Fatigue, weakness, reduced strength (4/5), slightly unsteady gait, and potential mild cognitive changes all significantly increase her risk of falls. Falls are a leading cause of injury, morbidity, and mortality in older adults, often triggering a cascade of decline.