solved

Question
Asked by patelamy33

Client Information

Name

Mr. Jack Henson

 

Age

DOB:   March 8, 1939 (72 years old)

 

Past Medical History HTN, DM type 2, Chronic Bronchitis and CAD. Mr. 
Medication

Aspirin 81 mg. daily

Mr. Henson was not adhering well to the medication regimen.

Allergies

NKDA

 

Tobacco  & Alcohol History

Used to smoke 1 pack/day but quit 7 years ago

Drinks socially

 

Social History

Lives with wife Maria in the same home they raised their children in- 2 storey- 3 bedroom home.

President and champion in local  Seniors bowling league

Retired TTC driver

 

Current Medical Condition

Mr. Henson was brought to Emergency Department 6 month ago with the following symptoms: weakness in the arm and leg, facial asymmetry, but the symptoms disappeared within couple of hours. Mr. Henson was discharged home with the following diagnosis (TIA). Mr. Henson was prescribed Aspirin and was instructed to adhere to his BP medications, but he was not following the instructions.  

1 month ago he suffered Right side ischemic stroke and was hospitalized.  As a result he has left side hemiplegia and left-sided neglect. He is unable to manage his personal care independently. Usually his wife helps with ADLs.

Case Study

You have been assigned to go to the Henson’s home to assist with personal hygiene and household management tasks.  His wife has recently been very ill with pneumonia and can’t manage assisting with his care these past few weeks.  Your schedule states you are to arrive at 0930h and you have two hours there to do the following:  assist with oral hygiene, showering, dressing and prepare lunch for the couple.  

When you arrive the client is in his room waiting for your assistance.  You have had Mr. Henson on your roster of care for two weeks now and come three times a week.  Today he appears to be sad.  When you ask what is wrong he states,” ever since this darn stroke I just feel useless. I can’t even be on my bowling team!” You offer support and ask permission to assist with his care and he agrees. While assisting in the shower you notice that the shower chair is broken. The wheel is missing and the chair is very unsteady.  Mrs. Henson says, “…it broke a few days ago in the shower and Jack hit badly his hip when it broke.”

      

 In the next space note five (5) priority concerns you would report and record for this visit. Use point form.  Please remember that priority means most important concerns or changes that happened, and that the purpose of documentation is both to communicate information and to CYB!

 

 

SCIENCE
HEALTH SCIENCE
NURSING
PSW 1001

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