Patient's Health Determinations
Our patient is an 88 y/o Portuguese female, related to a member of our group, who has asked to remain anonymous for her own privacy. Her past medical history consists of hypertension, angina, depression, osteoporosis, new onset dementia, B/L arm fracture, S/P ORIF of the left arm. About 3 years ago, our patient suffered a major fall in which she hit her head. She did not lose consciousness, however she did have a change in mental status, which led her family to take her to a trauma center. It was there that she and her family learned that she had suffered a significant left temporal lobe and frontal lobe hemorrhage with extension into the ventricles. This significant event, along with her past medical history and language barrier, has caused our patient to alternate between the homes of her two daughters. Our patient also has an adult son, but he resides out of state and does not contribute to her care.The patient attempts to complete as many ADL’s as possible, but has admitted that she has been limited and restricted as to what she is able to do independently, such as cooking. She makes a strong effort with walking and still helps with laundry, sewing, and enjoys gardening.
1. Assess patient’s level of comprehension and preferred method of learning, as well as patient’s understanding of her medical history and medication regimen.
2. Gather patient history and data as well as a general assessment of her well being, daily activities, and living conditions.
3. Develop a plan of care with the patient to address her specific needs.
4. Have patient create a list of personal goals she would like to achieve this week.
5. Perform teaching related to patient and family questions/concerns, chronic conditions, medications, and alternative therapies to her conditions.
6. Help develop a routine to help maintain activity and strength, both mentally and physically.
1. Assess progress and determine if interventions were maintained in our absence
2. Explore patient’s feelings and concerns regarding the interventions we have implemented
3. Evaluate the success of interventions and determine if any changes can and should be made
4. Assess medication regimen and ability to take meds as prescribed
5. Assist with meal plan for this week and educate patient on good diet and nutrition
1. Address family concerns in regards to patient’s ability to perform ADLs and manage personal hygiene, by assessing the patient in performing her daily routine.
2. Patient will continue to perform exercises, with modifications, for 1 hour daily
3. Assess home activities and perform teaching related to various activities that patient prefers.
4. Patient will take her medication as prescribed with some reminders
5. Patient will assist in developing meal plan