Home Visit for an Older Adult Living Alone
A community health nurse visits Mrs. Santos, 78, who lives alone in a second-floor apartment. She has hypertension, type 2 diabetes, and mild cognitive impairment. Her medications include metformin, lisinopril, and hydrochlorothiazide. On this visit: BP 168/92 mmHg, fasting glucose 210 mg/dL. She says she 'sometimes forgets' her pills. Her refrigerator contains mostly canned soup and bread. She reports two falls in the past month, neither reported to a provider. The stairs to her apartment have no handrail. She has a daughter who visits weekly.
1. Prioritize the identified problems and justify your ordering.
Read the worked answer
Priority problems:
- Falls risk - two falls in a month with no handrail and cognitive impairment; risk of fracture or head injury.
- Medication mismanagement - forgetting doses contributes to uncontrolled BP and glucose.
- Uncontrolled hypertension and hyperglycemia - chronic but currently elevated.
- Nutritional inadequacy - limited food variety.
Reasoning: Immediate safety (falls) outranks chronic disease control because a fall could cause acute, life-threatening injury. Medication adherence and diet are modifiable contributors to the chronic problems, so addressing them supports the others.
2. What specific, feasible interventions would you propose for the highest-priority problem?
Read the worked answer
Falls:
- Refer for home safety evaluation and installation of a handrail; explore community or Area Agency on Aging resources for funding.
- Review medications with the provider for fall-risk contributors (e.g., antihypertensives causing orthostasis).
- Encourage use of a cane or walker and proper footwear; remove throw rugs.
- Teach to rise slowly and to report falls.
- Involve the daughter in safety planning.
Reasoning: Interventions must be realistic for a patient with cognitive impairment living alone. Environmental modification plus caregiver involvement addresses the actual mechanism, not just education.
3. How would you address medication adherence without overburdening her?
Read the worked answer
Approach:
- Simplify the regimen if the provider agrees (e.g., combination products, once-daily dosing).
- Use a weekly pill organizer filled with the daughter's help.
- Set phone alarms or use a medication reminder app if she can use one.
- Link doses to daily routines (e.g., with breakfast).
- Involve the daughter in filling the organizer weekly.
- Reassess BP and glucose at follow-up to judge whether the plan is working.
Reasoning: With mild cognitive impairment, complex regimens fail. The plan should reduce cognitive load and build in a reliable support person, then be evaluated by outcomes rather than by whether teaching was given.