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.
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. write the "recommendation" section of the report that you would supply each person.
SBAR Report
Person providing report: RN case manager at in-patient rehabilitation unit in a long-term care facility.
Situation: Lois Gardner is a 75-year-old female we will be seeing weekly for assessment and medication management. She will be discharged from the rehab facility and returning to retirement housing with her husband Phil, who is her caregiver. We will be visiting in the rehabilitation facility to prepare for discharge home.
Background: Mrs. Gardner is a previous smoker and has a history of hypothyroidism, COPD and CHF.
She recently had a ten-day admission for treatment of COPD and pneumonia. She responded to antibiotics and respiratory treatments but is now using oxygen about half of the day.
She was sent from the hospital to a rehabilitation bed in a long-term care facility for pulmonary rehab. She had an MI at age 51 and has previous hospitalizations for pneumonia. She was seen in the ED two months ago for an episode of angina, treated with nitroglycerin.
Her ECG was normal, and she was sent home following that visit.
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 be progressively, slowly worsening. She was diagnosed with "non-specific dementia," probably vascular. Her husband takes care of most of the household duties. The nurses reported that he seemed overwhelmed with his responsibilities, and with determining the extent of her shortness of breath. She was unable to describe to him exactly what was going on and how severe it was. He is afraid to leave her alone.
Her daughter, Sharon, visits several times a week as do several couples from the Gardner's synagogue. Sharon lives about an hour away and comes after work. She sometimes brings her three children with her.
Assessment: Mrs. Gardner is intermittently confused, but cooperative. She becomes disoriented to place and time at night. She states her name and the names of her family. She is less consistent with the names of other visitors. She takes medications without difficulty when they are handed to her. She spends time watching Tv and looking out the window.
Vital signs are stable; she has been afebrile
She requires reminders to eat and drink, but she is independent at mealtime. GI assessment is normal
She has diminished lung sounds and requires reminders to take deep breaths and cough. Her pulse oximetry levels are stable, but she needs oxygen during meals and activity. She needs reminders to use her oxygen. She sleeps with several pillows.
Her muscle strength is good, but she is can only walk 15 feet with a walker without becoming short of breath. She is cooperative with physical therapy sessions.
She is continent and uses the commode.
Recommendation: Since she will be starting on home oxygen, a nebulizer, dietary modifications and physical therapy, her husband
needs support and encouragement. He needs education to implement the new orders. He has not sought any assistance from family members or outside agencies.
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.
