CASE 1
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| Nursing | Patient is able to independently monitor his BS using the FSBS Q unit. BS levels have remained within acceptable levels. BP has been 128/88 consistently. Pressure sore are remains minimally red. Patient is independent in monitoring his skin and able to identify warning signs of potential skin breakdown. Patient is managing other medications without difficulty. Patient has reported no falls in the last 3 weeks. |
| OT | |
| PT | Patient has demonstrated improvement in balance scores (Berg27/56, Get up and go 25 sec), however he remains at risk for falls. Pt’s endurance has improved. Is now able to ambulate 25 feet without becoming SOB. Needs continued PT to decrease risk for falls and improve endurance. |
| SW | See complete evaluation. |
| TR | See complete evaluation. |
1. Be able to communicate by e-mail using community resources with a selected group of contact with positioning to minimize stress on arthritic hands.
2. Decrease risk for falls
3. Improve endurance
4. Improve access to community based leisure activities that promote socialization and community reintegration.
5. Increase family involvement.
6. Evaluate and assist with finances to provide for medications, meal on wheels, house repairs and homemaker assistance when home health services are completed.
7.
MD to evaluate patient for pharmacological intervention for
depression.
| Nursing | continue seeing patient 1x/week for an additional 4 weeks. |
| OT | 1 visit with TR for assessment and
recommendations for transfers and functioning in the community |
| PT | Continue 1X/week for 2 weeks to decrease risk for falls and improve endurance |
| TR | Continue treatment 4 more visits to increase independence in accessing community resources and establishing networks for increased socialization |
| SW | Continue interventions 4 visits to address family involvement and assistance with finances. |
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