Mr. Robin Monera, an 81-year-old, is a new admission from the local hospital to your long-term care facility. After Mr.

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Mr. Robin Monera, an 81-year-old, is a new admission from
the local hospital to your long-term care facility. After Mr.
Monera’s last bout with pneumonia and congestive heart
failure, his wife of 59 years has decided she is no longer
able to care for him at home. Mrs. Monera states, “He has just
gotten too weak and can’t help me care for him. I am so afraid
he will fall and hurt himself. I am so worn out trying to
care for him myself. I have to bathe him and remind him
to eat; sometimes I’ve had to feed him myself or he
won’t eat. He can be so forgetful. I hope I am making
the right decision for him, because he never wanted to
go into a nursing home.”
1. Why is your admission assessment foundational to the care
of Mr. Monera?
2. Describe the four features of assessment and why they
are critical to ensuring positive outcomes within the context
of interdisciplinary care for Mr. Monera.
3. Describe how assessment is essential to the other steps of
the nursing process.
You are preparing to complete an initial comprehensive
assessment with Mr. Monera. This will include both the nursing
history interview and the observation/physical
examination.
4. Identify all primary and secondary sources of information
that you could use to help gather information about this
patient. Differentiate the types of data that can be elicited
from these sources.
5. Which special needs assessments, a type of focused
assessment, are indicated at this time? Discuss the data that
support your decision.
6. How will the observation of Mr. Monera during the initial
assessment contribute to the patient’s database?
You explain to Mr. and Mrs. Monera that you will be doing a
physical assessment to gather information to help establish a
plan of care. Mrs. Monera asks, “How do you do that and what
can it tell you about my husband’s status?”
7. Describe in simple terms the four techniques of examination
and the type of information you can elicit from the patient
pertinent to this patient’s present state of health.

In addition to the attainment of the physical data, it is important
to complete a thorough health history. This is done through
the nursing interview and is used to gather subjective data
for the nursing database.
8. How is the nursing health history different from the medical
health history?
9. Discuss how you will prepare yourself, Mr. and Mrs. Monera,
and the environment to enhance the data gathering inherent to
a health history.
10. For each of the following sections of the health history,
create a closed question and an open question, to elicit data
about that area specific to this patient.