PHYSICAL EXAMINATION & HEALTH ASSESSMENT

This case study gives you a great opportunity to use your well-honed skills–and sharpen them even further. Please answer the questions based on the case study, and dig deep! How good are you at identifying risk?

Millie Gardner, an 83-year-old female patient, is being discharged home today to the care of her husband Fred (87 years old) following a 9-day hospitalization for pneumonia, dehydration, and failure to thrive. She has a history of hypertension (HTN), Type II Diabetes, and cerebral vascular accident (CVA) with left-sided weakness. Patient is alert and oriented but does have periods of forgetfulness during the overnight hours. Patient has intermittent incontinence of bowel and bladder and requires assistance with all activities of daily living (ADLs).

Medications:

· Lopressor

· Lisinopril

· Plavix

· Metformin

· Novolin R per sliding scale *NEW*

· Multivitamin

· Colace

· Zithromax *NEW*

Upon arrival you are greeted by Champ, the couple’s rambunctious miniature Doberman pinscher dog. Millie is in her wheelchair staring blankly out the window, and Fred is busy in the kitchen preparing the couple’s lunch.

· Based on the scenario above, please use the general survey process to describe the areas that you would be observing immediately upon entry to the home.

· What, if any, concerns related to Millie’s skin and nutritional status do you have?

· What nursing interventions will you include in the plan of care to address these concerns?

· What teaching strategies will you use to educate Millie and Fred on the new medications?

· Using the SBAR, please include the information that you will communicate to the physician’s office at the completion of the visit.