ASSESSMENT & CARE PLAN
CLIENT CASE STUDY #2
Client Initials: VC
Date Admitted to Nursing Home: 12/14/07
Assessment Date: 12/3/10
1. HEALTH HISTORY
Brief description of health history and reason in nursing home: VC has a history of malignant neoplasm of her large intestine which lead to her colostomy status. She also has a history of fracture and fall. She was admitted to the nursing facility secondary to her alzheimer's diagnosis and decreasing ability to perform ADLs on her own, especially care for her colostomy.
Definition (include source)
Unspecified hemorrhage of GI
Bleeding in the GI tract from an unknown origin.
Not currently being treated
Alzheimer's disease is a disorder in which nerve cells (neurons) in the brain degenerate and eventually die (Mayo Clinic, 2010). Not currently being treated
Edema is swelling caused by excess fluid trapped in the body's tissues (Mayo Clinic, 2010). Lasix
Pain in joint
Discomfort that arises from any joint (Mayo Clinic, 2010).
Tylenol , Vicodin
Loss of bladder control
Not currently being treated
Depression is a medical illness that involves the mind and body. Major depressive disorder and clinical depression, it affects how you feel, think and behave (Mayo Clinic Staff, 2010). Zoloft
Chronic obstructive pulmonary disease (COPD) refers to a group of lung diseases that block airflow and make it increasingly difficult for you to breathe (Mayo Clinic, 2010). Albuterol
Persistently higher than normal blood pressure (BP). In adults, a condition in which the BP is higher than 140mmHg systolic or 90 mmHg diastolic on three separate readings recorded several weeks apart (Wilkinson & Van Leuven, 2007). Lasix
A group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning (Mayo Clinic, 2010). Not currently being treated
2. MEDICATION ADMINISTRATION PROFILES - Attached
Acetometophen 650mg po BID
ASA (baby aspirin) 81mg po QAM
Furosemide 20mg po QAM
Senna 8.6mg po BID
Zoloft 50mg po QD
Hydrocodone/Acetapinophen (Vicodin) 5/500mg BID PRN
Albuterol Inh q2hrs PRN
Magnesium Hydroxide 30 cc po PRN
Ducosate Sodium 10mg q3rd day if no results MOM PRN
Allergies (medications, foods, other): Atenolol/Remeron
Ideal Body Weight (IBW): 130-144
How often ht/wt obtained:
Rationale: monitor general health
Pattern/recent changes in weight (e.g., stable or amount of change, time frame): After admission, VC steadily lost weight but weight has remained stable for the last year.
Current diet (restrictions or modifications to food or fluids, any nutritional supplements used, rationale): Regular consistency, no added salt (NAS)
Intake and output:
Type and amount fluid intake (average/day for past 3 days): 1046cc/day Average % taken last 9 meals: 45%
General appearance and vitality (amount of physical activity): Older white female, spends entire day in wheelchair. Appears pale. Not aware of her surroundings. Low physical activity.
Recent range/pattern or relevant changes in VS: Vital signs have been relatively stable over the last month with minor fluctuations in temperature.
Musculoskeletal (activity level, posture and muscle tone, skeletal deformity): Posture imperfect, but pt has little ability to reposition herself. Pt uses her arms to move about in her wheelchair. Muscle tone appears flaccid, especially in legs.
Neurological/sensory (level of consciousness, orientation, cognitive ability, speech, coordination and balance, gait, strength, pupils,...
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