Anne Morell Case Study

Anne Morell is a seventy-four year old female with a past medical history of hyperlidemia, hypertension, osteoarthritis, osteoporosis, diabetes mellitus type 2, renal insufficiency, Charcot foot, and osteomosteomyeltits. Anne has a history of osteosarcoma treated in 1996 with surgery, chemotherapy and radiation. Anne also has a history of breast cancer, diagnosis in 2003 treated with radiation therapy. Anne past surgical history includes tonsillectomy in 1962, removal if osteosarcoma of left thigh in 1996 and lumpectomy of left breast in 2003.
On assessment, Anne’s reported height is 5’1” and weighs one hundred ninety one pounds. Based on Anne’s BMI, Anne is obese. Anne reports difficulty to adhere to a low carbohydrate diet and previous unsuccessful attempts at weight loss due to impaired physical mobility.
A Mini Nutritional Assessment (MNA) was completed on Anne. The MNA is a tool used to provide a rapid assessment of elderly patients’ nutritional status. The MNA is made up of simple measurements and a few brief questions that can be completed by the patient in no more than ten minutes. The nutritional status of a patient is evaluated using a two-step process to accurately determine a patient’s nutritional status (McGee

& Jensen 2000). Based on Anne’s MNA scores, the MNA classifies Anne as well nourished. The score’s Anne received indicates no specific follow-up is needed except to follow the Anne’s weight regularly at routine visits (McGee & Jensen 2000).
A healthy diet is important at any age, but even more significant for the geriatric
population. Adults that are older seem to be at a greater risk for nutritional deficiencies because of physiological changes that are associated with aging, illnesses, and functional decline. Among the many age-associated adjustments in nutrient requirements, energy expenditure appears to decrease with age because of a decrease in basal metabolic rate and physical activity. Perceptual changes, which happen later on in life, can also influence the nutrition in areas such as changes in taste and smell (Chernoff 2004). Other changes in bodily functions may impact an individual’s nutritional intake. Things such as gastrointestinal changes like delayed stomach emptying, constipation and gas may lead to elderly individuals avoiding healthy foods, such a fruits and vegetables (Everitt 2006).
A healthy diet should be encouraged for Anne. A healthy diet can reduce the risk of heart disease, stroke, hypertension, diabetes, and osteoporosis. Also, consuming fewer calories and more nutrient-dense foods, can help aid in weight loss (Everitt 2006). It is important for Anne to speak with a dietitian and create a meal plan to adhere to. Creating a meal plan not only will allow for Anne to follow a healthy diet, but allows Anne to have a sense of independence and control.
During Anne’s assessment, Anne reported difficulty with sleep. Anne was screened using both the Epworth Sleepiness scale (ESS) and Pittsburg Sleep Quality Index (PSQI). The Epworth Sleepiness scale assesses patients for excessive daytime drowsiness. Excessive daytime drowsiness is a concern in the geriatric population because it affects quality of life, daytime function and overall health. The ESS is not a diagnostic tool in itself. It is an assessment tool to determine or rule out sleep disorders that may be affecting their everyday sleep (Slater& Steier 2012). Anne results from the Epworth Sleepiness Scale resulted an average amount of daytime sleepiness. The PSQI is a subjective tool that can be used to measure the quality of sleep, as well as individual patterns of sleep in the common elderly adult. It differentiates that particular elderly individuals sleep gauging from “bad” to “good” sleep by measuring subjective sleep quality, duration, disturbances, use of medication, and daytime dysfunction over the last month (Smyth 2012). Anne reported only sleeping four to five hours a night of sleep, often awaking in the middle of the night due to pain and nocturia.
Sleep needs change over an individual’s lifetime. Unfortunately, it seems as though many older adults are getting less sleep than they need. Elderly adults produce and secrete less melatonin, the hormone that is directly related to and individual’s sleep pattern. Also, older adults may have some past medical problems that can affect their nighttime sleep. Insomnia and disrupted sleep in the geriatric population are often a direct result of many chronic medical conditions that todays elderly endure, such as congestive heart failure, gastroesophogeal reflux disorder, and in some cases depression (Deschenes & McCurry 2009). Chronic pain disorders such as osteoarthritis can cause stiffness in joints at night making the sleep difficult and painful. Medications can also affect sleep. For example, Beta-blockers can result in difficulty falling asleep, a large number of sudden awakenings, as well as vivid dreams. Additionally, caffeine is a stimulant that increases wakefulness. The effects of caffeine on an individual can last as long as fourteen hours and may be more conspicuous in an older patient because of a decrease in caffeine clearance with a decrease in liver function (Wolkove, Elkholy, Baltzan, & Palayew 2007).
Sleep deprivation can cause an individual to irregularly sleep during the day. Napping during the day can also reduce an individual’s ability to sleep through the night, potentially intensifying insomnia (Wolkove, Elkholy, Baltzan, & Palayew 2007). Inadequate or poor quality of sleep can lead to many problems. Older adults who are experiencing poor nighttime sleep habits are more likely to become depressed, encounter more nighttime falls, and use more prescription sleep aids (Wolkove, Elkholy, Baltzan, & Palayew 2007).
When sleep disturbances affect daily functioning, it is important to identify the cause of the sleep disturbance. Patients, like Anne, should be instructed to go to bed at the same time, wake up at the same time, and avoid things or activities that may result in “bad sleep” during the nighttime, like daytime napping, caffeine, and exercise at bedtime and so on. Sedentary patients should be pushed to start a daily exercise program that takes place in the morning, to improve sleep quality (Deschenes & McCurry 2009).
Anne reports a history of osteoarthritis. Osteoarthritis is a chronic disease. Osteoarthritis occurs when the cartilage or cushion between joints breaks down leading to pain, stiffness and swelling. This type of condition in older adults can significantly impact the ability of one to conduct normal everyday activities, such as walking, bathing, and performing household chores (Stamm, Pieber, Crevenna & Dorner, 2016). Anne reports increased pain with standing and walking, and the need for assistance with activities of daily living (ADL). There is no cure for osteoarthritis, but there are treatments that are available to manage symptoms.
Anne should be encouraged to exercise with a focus on strengthening to build muscles around targeted joints, ultimately easing the burden on joints and reducing pain in those specific areas. Also, range-of-motion (ROM) exercises should be encouraged. ROM exercises help improve, and even maintain joint flexibility and reduce joint stiffness. Assistive devices, such as scooters, walkers, canes etc., can help with an individuals function and mobility. (Stamm, Pieber, Crevenna & Dorner, 2016). Pain medication is recommended, however NSAID’s should be used with caution in older adults. Studies report significant increased risk of gastrointestinal bleeding, platelet inhibition and renal impairment in older adult patients (Mills & Raycroft 2012). Anne should be educated on pharmalogical pain management and speak with a physician before taking over the counter pain medications.
Anne also reports a history of Diabetes Mellitus type 2. Diabetes Mellitus Type 2 is a chronic condition that affects the metabolisim of glucose in the body. With Diabetes Mellitus Type 2, the body either resists the intended effects of insulin or it does not produce enough insulin on its own to maintain a healthy glucose level. Excess glucose in the can injure the walls of the blood vessels, causing permanent nerve damage. Nerve damage or poor blood flow to the feet will increase the risk of various foot complications. Charcot foot develops as a result of neuropathy, which decreases the ability to feel sensation (Vinik, Strotmeyer, Nakave, & Patel 2008). Anne not only reports a history Diabetes Mellitus Type 2 but neuropathy and Charcot foot as well.
Studies have found that older adults with poor peripheral nerve function have worse physical performance, poor balance, decreased muscle density and bone density. Additionally, evidence reports an increase of higher fall rates in older adults with neuropathy (Vinik, Strotmeyer, Nakave, & Patel 2008). Neuropathy can limit the ability of an individual to perform basic activities of daily limits and increases the risk of permanent immobility. It is important to educate older adults with Diabetes Mellitus type 2 of the importance of controlling their blood glucose. Unfortunately, diabetic neuropathy is irreversible and increases the risk of disability in older adults.
The Wear and Tear Theory is based on the idea that important tissues and vital cells wear out overtime as a result of overuse and the aging process (Mercado-Sáenz, Ruiz-Gómez, Morales-Moreno, & Martínez-Morillo 2010). An example of this theory is osteoarthritis. Osteoarthritis is a very common disabling condition affecting the geriatric population, including Anne. Osteoarthritis develops because of continuous mechanical wear and tear of a specific joint. Normal, healthy joint surfaces are surrounded with a smooth layer of cartilage. The cartilage that is covering the joint is deteriorated and worn thin in the causing osteoarthritis due to degeneration and the inability of the body to repair of the cartilage surface (Stamm, Pieber, Crevenna & Dorner, 2016). Unfortunately, there is no prevention of osteoarthritis; only surgical intervention can repair the affect joint.
A nursing diagnosis for Anne would include impaired physical mobility related to intolerance to activity (Herdman & North American Nursing Diagnosis Association 2012). Nursing interventions for impaired physical mobility would include treating Anne’s pain before activity and monitor for pain during activity. Also, implementing a walking program in which Anne walks every day, as part of a daily routine would be another nursing intervention. An additional intervention would include increasing Anne’s independence in performing activities of daily living, while discouraging feelings of helplessness as Anne’s strength improves.
Chronic pain related to inflammatory process would be an additional nursing diagnosis for Anne (Herdman & North American Nursing Diagnosis Association 2012). Nursing interventions would include encouraging Anne to manage pain with appropriate pharmalogical interventions such as Tylenol. Also encouraging Anne to use nonpharmalogical pain management such as alternating heat and cold compresses can help manage joint pain and reduce joint inflammation. An additional nursing intervention would include encouraging Anne to schedule daytime activities to provide for periods of rest during the day and continuous uninterrupted sleep at night.
In comparing and contrasting the differences between the patient Anne in the case study and the patient I interviewed, I notice many differences.

Anne is a seventy-four year old female with multiple comorbidities. The patient I interviewed is a sixty five year old male with a past medical history of hypothyroidism and no other reported medical conditions. Additionally, Anne requires assistance with completing her activities of daily living such as shopping, transportation and managing her finances. Also she rarely leaves her home, and is inactive due to chronic pain. The patient I interviewed is able to care for himself independently and is rather active. The patient I interviewed continues to work outside his home and routinely

exercises.
Additionally, Anne reports bored and lack of purpose as she ages, were the patient I interviewed denies such feelings. The patient I interviewed continues to work outside the home and states “fulfillment in his life.” I feel Anne and the patient I interviewed differ not only from a medical standpoint but from a psychosocial standpoint as well. I believe their individual outlooks on the aging process differ in many aspects. In completing this assignment, it is clear the aging process is individualized and varies from person to person.