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This Is An Example Of A Case Study Done On A Nursing Home Resident With Dementia. Includes Physical Assessment Data

2880 words - 12 pages

Running Head: Nursing Care StudyNursing Care StudyYour Name Goes HereName of Your College Goes HereGeneral InformationE.S. is a 94 year old female, born July 30, 1909. She is widowed. She is of Catholic religion. She stated that her mother was from Germany and her father was from Ireland. She is an only child, and never finished school because she married at a young age. Her date of admission was July 8, 2002 with the diagnosis of left hip fracture and dementia. She was hospitalized for the left hip fracture on July 2, 2002, and then transferred to the nursing facility due to the inability of client to care for herself, as evidenced by inability to remember if she took her medication and needing assistance when toileting. Her code status is a DNR, comfort measures only. Antibiotics for infections are ok, but no feeding tubes or IV fluids. She has full upper and partial lower dentures. She receives a bed bath and has her nails and hair done once a week. She uses a wheelchair for ambulation, she needs assistance to help rise from her wheelchair to stand, and is unable to walk. Activity level is limited to those of which can be done in a wheelchair. She needs stand-by assistance with toileting and helping with transfers to and from her wheelchair.History of Present IllnessPatient and Chart InformationChronological Development of Clients Number One Medical DiagnosisE.S.'s primary medical diagnosis is dementia. Her hip fracture may have been caused by changes in muscle coordination/balance, which is a symptom of dementia (Doenges, Moorhouse, & Geissler, 2002). She now uses a wheelchair for ambulation and needs assistance to transfer to and from her wheelchair. Her hip fracture has now healed, but she is still unable to care for herself due to her decline in cognitive abilities.Current Signs and SymptomsCurrent signs and symptoms of client's primary diagnosis of dementia include forgetfulness, inability to determine whether or not a task had been performed, as evidenced by not being able to remember if she had cleaned her teeth or taken her medications. Inability to recall factual information or recent/past events, as evidenced by inability to orient herself to residence, or if her son had returned from his vacation. She has expressed fear of further mental/physical deterioration by stating that she cannot stand the thought of, "not being able to do anything but lay there and depend on everyone to take care of me, and can't talk." She has been diagnosed with depression which is often associated with dementia (from chart). She tries to remember the names of people in her photographs and then gets frustrated as evidenced by client stating "I'm just going to put this away and never look at it again." She is unable to orient herself to time (does not know the season, or what year it is). Client has edema in her ankles related to her immobility. She is also underweight and has difficulty swallowing.Textbook InformationDementia is a general term for a...

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