Integrated Health Care Assignment
Added on 2021-04-16
12 Pages4018 Words84 Views
Running head: INTEGRATED CARE PLANIntegrated Care PlanName of the studentUniversity nameAuthor’s note
1INTEGRATED CARE PLANIntroduction:Diabetes is the most common cause of death among elderly patients and other populations alike. Diabetes is also a multi-factorial disease thatoccurs in people associated with other health issues like obesity, chronic heart diseases, kidney diseases and the leading cause of hospitalizationsamong geriatric patients. The case study describes a female patient who is 65 years old, having a medical history of diabetes for twenty years.The patient was admitted in the hospital from the emergency department with a case of severe glycemic shock, difficulty in breathing and severeback pain. On diagnosis, the reports showed that the patient has cardiac blockage, is currently obese with hypertension symptoms. The patientwas also asses by Beck depression Inventory and showed positive results suggesting she was suffering from clinical depression but did not takeany medication prior to this admission. The back pain of the patient was treated with pain medication to minimize the pain score. The reportsummarizes the care plan set up for the patient with reference to the current condition to treat her glycemic shock, administration of medicationfor the condition and address the heart blockage and depression as well. Patient education is also an important factor for the completion of thecare plan and the family of the patient was taught so that the home care can be arranged properly so as to reduce risk of hospital readmission.The family of the patient was also taught to monitor the patient to avoid the risk of falling which might cause severe repercussions, which iscommonly observed in geriatric patients.Objective DataRespiratoryPulse ox: 89% showing low levelsCough: No such detectionSputum: not detectedOxygen: room temperature Respiratory rate: 140/90 mm Hg very high,as seen in hypertensive patientsTachypneic/Hypoventilation(tooslow/shallow: Respiratory effort: effort required due toblockage in heartRespiratory rhythm: difficult, erratic andvery high due to heart blockageBreath sounds: no wheezing is observed, butbreath rate very highCirculatorySkin: WNL, normal Skin Turgor: TentingWeight: 90kg/lb, overweightCapillary refill: WNLApical pulse rhythm: irregularity seenApical pulse rate: Tachycardia beats noted Heart Sounds: (Arrhythmic sounds noted) causedby hypertensionApical/radial deficit: yesPeripheral pulses: 80mmHgR radical= Doppler, R femoral= yes, Rpedal=yes, R post tib=yes; L radical = yes, Lfemoral= Doppler, L pedal= yes, L post tib= yes.Edema: none such detected in the chest or throat,so no possible pathogenesis is the cause ofbreathing troubleR Hand/arm= no, R knee to thigh= no, R ankleNeurologicalOriented to : patientCommunication : slow but expressive Pupils:round, with a sluggish reaction to light. Glasgow Coma Scale(score range 0-15,Coma=<7): a.Eye opening to: spontaneous=3, verbalcommand =2, pain=0, no response=1.b.Verbal responses to: slow and effort,converses=4, disoriented, converses=3,usesinappropriatewords=4,incomprehensible sounds=1, noresponse=1. c.Motor responses to: verbal command = 5,localized pain=6, flexes and withdraws=3,flexes abnormally (decorticate)=4, extendsabnormally (decerebrate)=3, no response =1. Muscle tone & strength
2INTEGRATED CARE PLANto knee= non-pitting, R foot/ankle=no; LHand/arm= no, L knee to thigh= no, L ankle toknee= no, foot/ankle=non pitting, Sacrum=non-pitting. Heart blockage noticed and needs immediateassistance. Deprivation of sleep due to difficulty inbreathing Head/ neck: flaccid, Right hand: spastic, L Hand:flaccid, RUE: LUE: flaccid, RLE: flaccid, LLE:flaccid. The muscle on the leg seem to be stressed due toher weight and mild oedema is noticed on thejoints due to pressure of weight.Legs: unable to walk properly due to weight gainDepression measurement: scored out of BeckDepression InventoryErratic moodLow self esteemSense of failureLack of self confidenceBody image issuesPity on selfOld age depressionLack of satisfactionSlow movementConstant sighsInability to expressDemotivatedboredom
3INTEGRATED CARE PLANMusculoskeletalGait: Appearance and no movement Arms: Appearance and movementLegs: Appearance and cannot walkSpine: Appearance and difficulty in movingPainLocation of pain: back pain and soreness in legsLoss of activity: walking is being affected by thepainDescription of pain: sharp and locatedPain rating on a scale of 0-10: 6Acceptable level for this client: 5What makes the pain worse: walking andmovementWhat makes the pain decrease: medication, andsleep.Psychosocial (and other relevant data)patient’s name: Surinder Kaurgender: Femalebirth date/age: 65Marital status: MarriedRace/ethnicity: Indianlanguages spoken: English No such mental illness but chronic depressionHistory: diabetes for 20 years and takes dailyinsulinObese: 90kg/lbHypertensionWeight gain is the cause of depressionCurrently no medication is provided fordepressionUnable to walk due to obesitySuffers from hypertension and back painInability to walk
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