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III. NursingAssessment1.

PersonalHistory1.1

PatientsProfile Name:

Mrs. Torralba,


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LourdesAge: 89years oldSex:

FemaleCivilStatus:

WidowReligion: Roman

CatholicDate


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and time ofadmission;

March 13, 2008at 10:10

amRoom No.:Room 425,

Cebu Doctors


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UniversityHospitalCompla

ints: Pain theright

hipImpressionor Diagnosis:

Fracture Close-


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Comminuted:Femoral Right

Neck GeneralOsteoporosisBr

east Cancel(Right)Diabetes

Mellitus Type


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IIPhysician: Dr.F. Vicuna, Dr.

E. Lee, Dr. N.Uy, Dr.

RamiroHospitalNo: 216 4261.2.

Family and


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IndividualInformation,

Social andHealth

History Mrs.Torralba,

Lourdes


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who resides in 8Acacia St.

Camputhaw Lahug,

Cebu City,CebuProvince with 9

successful


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children ( 6boys and 3

girls) wasadmitted to

CebuDoctors University

Hospital for


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furthermanagement of

thecondition.Mrs.

Torralba is acollege

graduate and


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shespreviously

working as anassistant of

her husband (Mr. Rodrigo

Torrralba ) a


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doctor.Thepatient was

diagnosed tohave Breast

Cancer (Right)last 2006 with

bonemetastasis


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and onchemotherapy

with aromasin.4

Two days prior

to admission,the patient was

standing and


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was about toopen uphe

umbrella whenshe got out of

balance andlanded on her

right hip.And


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hadexperiencedlimi

tation ofmovement on

the right hip.The patient

was then


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admitted due tothe persistence

of pain.Thepatient was

previouslyhospitalized

due to infected


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wound at theright anklelast

2002. Nofamilial history

of hypertensionand bronchial

asthma but is


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positivetodiabetes

mellitus ofpaternal side.

Has no knownfood and drug

allergies. The


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patient isnon-smoker non-

alcoholicbeverages

drinker.1.3.Level of

Growth and


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Development1.3.1. Normal

Growth andDevelopment at

particular stageOlder Adult (

65Years old to


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death)PhysicalDevelopmentPe

rception ofwell-being can

define quality oflife.

Understanding


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the olderadults perceptio

n about health status is essential

for accurate assessment and dev

elopment of clin


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ically relevantinterventions.

Older adultsconcepts of

health generallydepend

on personal perc


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living usually consider themsel

veshealthy, wherea

s thosewhose activities

arelimited by


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physical,emotional or

socialimpairments

may perceivethemselves as

ill.There are


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frequentlyobserved

physiologicalchanges in

order adultsthat arecalled

normal. Finding


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these normalchanges during

and assessmentis not an

expected.Thesephysiological

changes are not


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alwayspathological

processes inthemselves,

butthey maymake older

adults more


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vulnerable tosome common

clinicalconditions

anddiseases.Some older

adults


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experience allof these

physiologicalchanges, and

othersonlyexperience

only a few.


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The bodychanges

continuouslywith age,

and specificeffects

on particular


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older adultsdepend on

health, lifestyle,stressors and

environmentalconditions. 5


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CognitiveDevelopmentInt

ellectual capacity includes per

ception, cognitive, memory, an

d learning.Perc


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eption, or theability to

interpret theenvironment,

depends on theacuteness of

thesenses. If the


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aging personssenses are

impaired, theability to

perceive theenvironmentand

react


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appropriately isdiminished.

Perceptualcapacity may be

affected bychanges inthe

nervous system


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as well.Cognitive

ability, or theability to know,

is related tothe perceptual

ability.Changes


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in cognitivestructure occur

as a personages. It is

believe thatthere is

a progressive


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loss of neurons.In addition,

blood flow tothe brain

decreases, themeaningesappea

r to thicken, and


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brainmetabolism

slows. As yet,little is known

about the effectof these

physical


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changes on thecognitive

functioning ofthe older adult.

Older peopleneedaddition

time for


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learning,largely because

of the problemof retrieving

information.Motivation is also

important.


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Older adultshave more

difficulty thanyounger ones

inlearninginformation

they do not


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considermeaningful. It

is suggestedthat the

older person mentally active to

maintain cogniti


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ve ability at thehighest possible

level. Lifelongmental activity,

particularlyverbal activity,

helps the older


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person retainthe

highlevel of cognitive functio

n and may helpmaintain a lon

g-


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term memory.Cognitiveimpai

rment thatinterferes with

normal life isnot considered

part of normal


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aging. Adeclinein intellectual

abilities thatinterferes with

social oroccupational

functions


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shouldalways beregarded as

abnormal.Psychosocial

DevelopmentAccording

to Erikson,


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the developmental task at this

time is egointegrity

versusdespair.People who

attain ego


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integrity viewwith a sense of

wholeness andderivesatisfacti

on from pastaccomplishmen

t. They view


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death as anacceptable

completion.According to

Erikson,people who

develop


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integrity acceptones one and

only lifestyle.By contrast,

people whodespair often

believe they


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have made poorchoices

duringlife andwish they have

made poorchoices during

life and wish


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they could livelife over.Robert

Butler seesintegrity and

bringingserenity and

wisdom, and


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despair asresulting in6the inability toaccept ones

fate. Despairgives rise of

frustration, this


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couragement,and asense that

ones life hasbeen worthless

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