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Assessment & Care Plan Essay

2039 words - 9 pages

ASSESSMENT & CARE PLAN

CLIENT CASE STUDY #2 Student: Fall 2010

Client Initials: VC Age: 82 Gender: Female

Date Admitted to Nursing Home: 12/14/07 Assessment Date: 12/3/10

1. HEALTH HISTORY

Brief description of health history and reason in nursing home:
VC has a history of malignant neoplasm of her large intestine which lead to her colostomy status. She also has a history of fracture and fall. She was admitted to the nursing facility secondary to her alzheimer's diagnosis and decreasing ability to perform ADLs on her own, especially care for her colostomy.

Medical Diagnoses
|Diagnoses |Definition (include source) ...view middle of the document...

| |
| | | |
|Urinary Incontinence |Loss of bladder control |Not currently being treated |
|Depressive Disorder |Depression is a medical illness that |Zoloft |
| |involves the mind and body. Major | |
| |depressive disorder and clinical | |
| |depression, it affects how you feel, think| |
| |and behave (Mayo Clinic Staff, 2010). | |
| | | |
|COPD/RAD |Chronic obstructive pulmonary disease |Albuterol |
| |(COPD) refers to a group of lung diseases | |
| |that block airflow and make it | |
| |increasingly difficult for you to breathe | |
| |(Mayo Clinic, 2010). | |
|Essential hyertension |Persistently higher than normal blood |Lasix |
| |pressure (BP). In adults, a condition in | |
| |which the BP is higher than 140mmHg | |
| |systolic or 90 mmHg diastolic on three | |
| |separate readings recorded several weeks | |
| |apart (Wilkinson & Van Leuven, 2007). | |
|Dementia |A group of symptoms affecting intellectual|Not currently being treated |
| |and social abilities severely enough to | |
| |interfere with daily functioning (Mayo | |
| ...

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