Question Answered step-by-step Patient: Mr Sydney Sheldon. Age: 86 years of age. (DOB 11/06/1934)… Patient: Mr Sydney Sheldon. Age: 86 years of age. (DOB 11/06/1934)Address: 25 Elms Ave, Doncaster 3108. UR: 123456Admitting Doctor: Dr WantAdmission Diagnosis: bronchitis & investigation of fall.Past History: Asthma. Hypertension. Osteo Arthritis. A series of falls over the past few weeks with increase in frequency in recent months.Lethargic, short of breath and fever.Additional Medical History: UTI & Postural Hypotension.Medication: Antihypertensive (Withheld as per Dr Order). Panadol osteo (ii 6/24). Ventolin puffer (PRN). Oral antibiotic Amoxicillin (TDS).NOK: wife,ADL’s: Frequent Voiding. Reduced mobility due to pain associated with OA.Ambulate with assistance, reduced ability to perform ADL’s. Social: Mr Sheldon lives in his own home with his wife.Mr Sheldon is getting increasingly difficult to manage at home.Primary carer: Wife (who is 84 years old, is quite frail and displaying early signs of dementia). Current Vital Signs: T 36.7, P72, R 18, SaO2 98% on RA, 110/78. GCS= 15. Mr Sheldon is suffering from urine frequency. Mr Sheldon scraped his left lower leg on the door of the bathroom shortly after admission. He is still feeling light headed when he stands up. As a result of your nursing care measures since admission, (conducting lying and standing BP, each time you perform vital signs), Dr Want decides to withhold Mr Sheldon”s hypertensive medication.You commenced a fluid balance chart on Mr Sheldon on his admission. This chart indicated that Mr Sheldon was voiding frequent, small amounts of urine into the urinal bottle. You conducted a Full ward urine test. Mr Sheldon’s urine is indicating a potential urine infection. The MSU test results confirms an infection. Mr Sheldon was commenced on oral antibiotics to treat this infection..Mr Sheldon is seen by the dietician and a review of his daily nutritional intake is undertaken by the dietician. With the assistance of the RN you instigate a continued strict FBC and meal chart. You educate Mr Sheldon on the importance of eating his meals or informing you if he is unable to eat.You remind him you are still recording his fluid intake and output (FBC) and gain ongoing compliance from him. The antibiotic treatment appears to be resolving the UTI with Mr Sheldon voiding frequency reduced, and daily Urinalysis showing No abnormalities. Nil Blood, nil protein, nil Ketones and nil leukocytes. T 36.7. No complaints of nausea. Dr Want has made the decision to refer Mr Sheldon to:-A Physiotherapist to assist with Chest physio, gait and mobility assessment. A social worker is engaged to assess the home, living arrangements, access to services, council services (meals on wheels & home help), and to assess Mrs Sheldon’s capacity to care for her husband on his return home. The occupational therapist is also engaged to review Mr Sheldon’s ability to move around his house, the need for hand rails and aids etc, to ensure home safety.Both the occupational therapist and the social worker arrange for in home care services, meals on wheels. Dr Want also writes a referral for the district nurse service for wound care.The Social worker liaises with family resulting in a Personal care attendant to visit 6 days a week to assist with ADL’s for the Sheldon. An interdisciplinary team meeting resulted in Dr Want agreeing to refer Mr Sheldon to a rehabilitation centre for 10 days, for reconditioning, prior to going home with new services in place.Dr Want writes a discharge plan, transfer letter and referral letter to the Rehabilitation Physician. Q. List the health team members that a referral would be required, before Mr Sheldon discharge to rehabilitation centre? You document in patient progress notes and NCP – the current nursing care and changes to medication treatment for your patient. You continue to remind Mr Sheldon to using bottle to void and having call bell within reach. You instigate mobility exercises as per Physiotherapist orders.You document all allied health care team members visits to your patient and instigate additional plans for Mr Sheldon’s ongoing care.You reinforce the education re care and pending transfer to rehabilitation centre of Mr Sheldon with him and his wife.This information will form part of nursing intervention to prevent further episodes of pressure risk, potential falls, Fluid balance issues, resolution of urinary tract infection and continued assessment of Neurological and Neurovascular status and current vital signs for Mr Sheldon.The RN ensures all referrals are in place in preparation for Mr Sheldon’s transfer to Rehabilitation Centre.You remind the RN to book the non-time critical transport for Mr Sheldon’s Transfer to new facility (Rehab unit).You commence writing up Mr Sheldon’s Discharge/transfer plan in readiness for his transfer.You do a transfer ISBAR document in preparation for Hand over to new hospital. Write Some Progress Note with the above information. Include your interventions. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)
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