This is the final assignment for submission of your Project. It must include the client/family overview, smart goal, case management assessment, care goals/objectives, resource management, and client/family teaching plan. You must use accurate spelling and grammar and APA Editorial Format
Case study summary:
People suffering from prolonged sicknesses and some comorbid situations have complexity guidelines that demand thorough caregiver engagement, more convoluting the challenging care process. The interview day brought us to a rehabilitation center where some of the patients are able to do for themselves with a little assistance and some that need complete care. Those that go into a career in the medical field will come across all types of patients, including those patients who need assistance as well as the patients who are total care. Regardless of the patient’s condition, they should all be treated the same. All patients should be treated with kindness and respect above all else.
I interviewed at the facility that goes by the initials D.O. D.O was born in 1965 making him 54 years old. I got the privilege to speaking with him and ask him about his childhood. Talking to him about his childhood and it put a smile on his face. I am guessing he had a pleasant flash back of growing up reminding her of her parents and siblings. D.O is the youngest of 4children, 2 boys and 2girls. He did most of the hard work while his sisters always in the kitchen with his mother preparing meals. He stated he was raised on a farm but had most of the hard labor. He still tries to be creative today but his condition due to TBI, stroke HTN, diabetics does not help him too much to be creative.
His health over the years as he explained it went downhill. As a child he was very healthy with no major issues or concerns. All his immunizations were up to date, which still holds true today after going over his chart information. This resident is a total care which means he depends on the help of the nursing staff in the facility to keep him going, to keep him active, to keep him in a good and stable condition. According to him is allergic to milk and that’s all that’s really bothering him besides the diagnosis presented in his chart. When I asked the resident about any fractures, he stated that the only fracture he got growing up was a broken arm from playing rough with his siblings. He stated it healed well and had no issues with any other fractures
He stated that he understood he is taking medication for “a lot of things”, as he puts it. He does not mind taking the pills, but he thinks that the nurses that give them to him do not have patience with him when it comes time to take them. He can use his arms, but he says his throat is kind of dry, so he must take his time. One of the medications he takes is oxycodone which l believe this medication is for the pain he feels because he is essentially bed ridden. He cannot move on his own and it may be painful at some point or another. This medication is given in the mid-day and prn and I am sure if her pain increased this medication can be increased as well. He is taking a plethora of other medications most of them used to nerve pain and her diabetes.
Diabetes is a condition that affects the entire body. Secondary conditions usually become present with diabetes. He was diagnosed with type-two diabetes and he takes insulin for this condition. The dose of insulin would depend on the glucose level present each time his tested. The client is tested before breakfast, again before lunch and another time before dinner. Another pill that he takes is a multivitamin; this is to assist his body with the vitamins and minerals that need to be supplemented such as calcium and vitamin D for his bones. Other benefits of the multivitamin include B6 and B12. Both B vitamins are essential for the body. These vitamins can also assist with his diagnosis as well.
The patient’s family medical history is not extensive, the patient states that his siblings and his mum still living. He stated he always afraid of getting cancer so he checked himself as much as he could. He stated besides his mother his family was free of conditions and diseases his only health concern is being more active. He wants to get up more often to be more active at least once or twice a week. Which I think is reasonable for him however the patient also stated “I know they have other patients who needs help and that’s why I can’t get up”. The patient is aware and understanding of his environment as well as day-to-day activities. His only concern is more activity; hopefully the facility can provide him with that.
As far as basic psych-social health is not too active today he is bed ridden and does not practice as much social activity as he would like. He gets frequent visits from his mother and siblings. The only social activity this resident sees is from his roommate and the caregivers (Nurse aide, occupational therapy and physical therapy), that care for his daily. He does make frequent calls to his family to speak with them as much as he can. Other than that, he has to wait for them to come and see him. He states that makes him the happiest, seeing his family.
I asked him what he believes his stressors are and he stated that his only stress is not being able to move and get out of bed and listening to music. He wants to be able to get up and be more social. He also stated that when he becomes to stressed and anxious, he takes Xanax. I did not see this in his chart, but this might be a new medication or something he used to take before being admitted. One interesting piece of information about him is the fact that his chart states his confused occasionally due to his TBI. It also states in his chart that he is alert times three and has no other signs of dementia other than being a confused.
Overall, his as a pleasant man who came to this facility because his family wanted more care for him. He needed around the clock care after his stroke and as many medications as he takes his family would not be able to care for him as he needs. He understands he does not want to burden his family but would love for them to come see him more. Altogether, he is a pleasant man who just wants to get moving a little more.