Nursing Case Study

776 Words 4 Pages
Ms. RS is a 95 y/o African-American female seen and evaluated at Hartford Nursing and Rehab Facility for monthly renewal. Resident was sitting in her wheelchair in her room. She was pleasant on approach and she was able to verbalize her needs. Resident did not appear to be in any acute distress at this time. She states that she feels better that last week, but occasionally experiences cramps in her lower legs. She states that has similar episodes in the past that resolve in a few days. She reports no other symptoms.
Reflecting back on my history taking, I think that I did pretty well. I listened attentively, maintained good eye contact, and let the resident express her concerns. The resident’s length of stay was more than a year. So, I mostly
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PLAN

1. Parkinson’s Disease- No tremors noted. On Carbidopa. Maintain safety and fall precautions. Monitor for s/s of tremors to hands.
2. Unspecified Osteoarthritis, Unspecified Site- Occasional complains of pain in BLE. Continue Tylenol ER PRN. Continue to maintain safety and fall precautions. Encourage restorative nursing therapy as tolerated.
3. Essential (Primary) Hypertension- Controlled. Continue with Amlodipine and ASA. Continue to monitor blood pressure and heart rate per facility protocol. Target BP <140/90.
4. Type 2 DM with Diabetic Neuropathy-Blood Glucose on 10/14/16- 89, HBG A1C-7.3 on 8/31/16. No s/s of hyper/hypoglycemia. Diet controlled. Check HBG A1C now and then every 3 months. Her neuropathy is controlled with Gabapentin. Continue to monitor for s/s of numbness and tingling in hands and feet.
5. Disorder of Lipoprotein Metabolism, Unspecified- Continue Atorvastatin. Check Lipid panel December
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Unspecified Sequelae of Cerebral Infarct- Continue with preventative ASA. Continue to maintain safety and fall precautions.
8. Weakness- BLE weakness present. Continue to encourage participation in restorative nursing therapy. Maintain safety and fall precautions. Continue Tylenol Arthritis for pain.
9. GERD without Esophagitis- Controlled. Continue Protonix. Monitor for s/s of n/v/indigestion, and abdominal pain.
10. Unspecified Open-Angle Glaucoma, Stage Unspecified- Her vision does not interfere with the performance of her daily activities. Continue Brimonidine Eye Drops. Follow-up with Ophthalmologist as needed.
11. Heart Failure, Unspecified- No shortness of breath. Bilateral 3+ pedal edema. Continue Lasix and Potassium. Check CMP now then q 3months. Encourage resident to elevate legs at least 3x a day when in bed and w/c.
12. Unspecified Iridocyclitis (Uveitis)- Denies any complaints of pain in bilateral eyes. No drainage. Continue Cosopt Eye Drops and FML Forte Eye Drops. Monitor for vision changes. F/u with Ophthalmologist as needed.
13. Gout unspecified: controlled continue with allopurinol as ordered monitor for s/s of increase uric acid.
14. Constipation, Unspecified- Controlled. Continue MOM and

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