ASSESSMENT & CARE PLAN
ASSESSMENT & CARE PLAN
CLIENT CASE STUDY #2 Student: Fall 2010
Client Initials: VC Age: 82 Gender: Female
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.
Medical Diagnoses
Diagnoses
Definition (include source)
Related Medications
Unspecified hemorrhage of GI
Bleeding in the GI tract from an unknown origin.
Not currently being treated
Alzheimer's Disease
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
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
Urinary Incontinence
Loss of bladder control
Not currently being treated
Depressive Disorder
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
COPD/RAD
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
Essential hyertension
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
Dementia
A group of symptoms affecting intellectual and social
CLIENT CASE STUDY #2 Student: Fall 2010
Client Initials: VC Age: 82 Gender: Female
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.
Medical Diagnoses
Diagnoses
Definition (include source)
Related Medications
Unspecified hemorrhage of GI
Bleeding in the GI tract from an unknown origin.
Not currently being treated
Alzheimer's Disease
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
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
Urinary Incontinence
Loss of bladder control
Not currently being treated
Depressive Disorder
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
COPD/RAD
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
Essential hyertension
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
Dementia
A group of symptoms affecting intellectual and social