Background info************* Lois Gardner Married to Phil Gardner since age 49. Lois has a sister Dorothy who lives with her husband a few hours away. Lois’s adult daughter Sharon lives about an hour away. She is a real estate agent with a 16-year-old son, a 14- year-old daughter and an 8-year-old daughter. Lois has had signs of confusion and memory loss for over a year and was officially diagnosed with dementia by her neurologist after her hospitalization 6 months ago. She is on Medicare and supplemental insurance.
Husband Phil is Lois’s caregiver. He has not had help from others in caring for Lois. Phil is now responsible for cooking and most of the household duties. Lois helps as able with tasks like washing dishes and folding laundry. Phil is mostly confined to the house, though he will occasionally leave for an hour or two to shop, run errands, and meet friends for coffee or lunch. Lois is able to accompany him to the store and does that at times. Otherwise she has few interests and spends her time watching TV or looking out the window. They both enjoy occasional visits from her daughter and the children. Name: Lois Gardner Caregiver: Phil Gardner Date of Birth: 2/12/19XX Age: 75 Gender: Female Weight: 126 lbs. ( kg) Height: 5’4” Race: Caucasian Religion: Jewish Major Support: husband Phil Gardner Allergies: Penicillin Immunizations: Current including influenza Diagnosis Past medical history: Chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), myocardial infarction (MI) age 51.
Hospitalized for pneumonia 6 months ago. Following discharge, evaluated by neurologist and diagnosed with dementia. Current diagnosis: COPD, CHF, post MI Situation: Lois Gardner is a 75-year-old female we will be seeing monthly for assessment and medication management. She lives in retirement housing with her husband Phil, who is her caregiver. This will be our first visit. Background: Mrs. Gardner is a previous smoker and has a history of hypothyroidism, COPD and CHF. She had an MI at age 51 and was hospitalized for pneumonia 6 months ago.
She was seen in the ED last week for an episode of angina, treated with nitroglycerin. Her ECG was normal, and she was sent home. Her home medications include: Levothyroxine 88 mcg oral Monday, Wednesday, and Friday; 100 mcg oral Sunday, Tuesday, Thursday, and Saturday. Metoprolol 50 mg oral daily Atorvastatin 20 mg oral daily Aspirin 81 mg oral daily Albuterol 2 puffs every 6 hours via inhaler, Salmeterol 1 inhalation every 12 hours via inhaler. Nitroglycerin mg sublingual as needed for chest pain She sometimes takes acetaminophen or Ibuprofen orally over the counter for discomfort.
Her husband reports that she has become more confused and forgetful over the past year and a half and requires help with medications and other tasks. This seems to have worsened since her hospitalization for pneumonia 6 months ago. Dr. Wong referred Lois to neurology after that hospitalization and she was diagnosed with “non-specific dementia,” vascular. Her husband takes care of most of the household duties. The ED nurses reported that he seemed overwhelmed with his responsibilities, and with determining the extent of her chest pain. She was unable to describe to him exactly what was going on and how severe it was. Assessment: Mrs. Gardner was stable upon discharge from the ED. She continues on her home meds, which include nitroglycerin PRN for chest pain.
Her husband needs support and encouragement. He has not sought any assistance from family members or outside agencies. Recommendation: Review medications that Phil is administering to Mrs. Gardner. Assess the home for safety. Questions: Initial Posting: In order to provide patient-centered care, the nurse uses forethought to address possible strengths and indicators of risk in an individual family’s setting.
The nurse implements anticipatory planning to promote safety. In your initial post:
• Considering the rehab case manager report and the medical record information, describe three strengths in the Gardner family that the nurse would incorporate into the plan of care. To identify the strengths, consider family structure, setting and resources.
• List three to four members of the interdisciplinary team and/or community resources, that the nurse would use in this setting. To facilitate the team members’ participation, the nurse will give an SBAR report to each person. For your assignment, write the “recommendation” section of the report that you would supply each person.
