Appendix C. Case Study and Program Examples | Agency for Healthcare Research & Quality

 

patient case study example

Step Three—Record Circumstances, Patient Outcome and Staff Response. A Tracking Record for Improving Patient Safety (TRIPS) should be completed by the nurse in charge within 24 hours of Mrs. P's falls. A separate TRIPS form should be completed for each fall. See the sample TRIPS form. Step Four—FAX Alert to Primary Care Provider. Apr 07,  · Nursing Assignment Free Sample on Nursing Case Study made by our PhD Nursing Assignment Help Experts Call +1() or LiveChat now Nursing Assignment Sample on Nursing Case Study. Posted on April 7, Patient muscle coordination's and weakness improves/5(). Patient Mr. NCS is a 53 year old Chinese man with the height of m, and weighs 82kg where his BMI is kg/m2 (overweight). Case Study Of A Patient With Diabetes Mellitus Nursing Essay. words (16 pages) Essay in Nursing. 5/12/16 Nursing Reference this Disclaimer: This work has .



Skip to Main Content. P is a 93 year old white female admitted to your facility. She has had Alzheimer's disease for approximately 7 years and has been cared for patient case study example her husband and daughter at home. Her patient case study example past medical patient case study example include: diabetes mellitus, hypertension, osteoarthritis, depression and a history of falls.

Over the past several months, her family has found it increasingly difficult to care for her at home due to worsening agitation and insomnia.

P has been at your facility for 3 days and has slept only 3 hours per night. She is extremely restless and anxious and often cries out for her husband. She constantly wants to get up from her chair or bed. P was found on the floor by staff at 8 pm and apparently had fallen onto her buttocks; no injuries were found.

P was assisted to bed for the night. A waist restraint was placed on her and all four side rails were positioned in the upright position. Later that evening Mrs. P was found on the floor. Her undergarments were soiled and she continued to cry out for her husband. She was assessed to have no injuries resulting from the fall. The nurse obtained an order for a sedative from the physician and Ativan 1.

Patient case study example was put back to bed and finally went to sleep for the night. S: Mrs. P was found on the floor in her room at 8 pm this evening. Resident states "I was needing to use the restroom. P has been agitated and restless off and on since admission and has been showing other signs of unsafe behavior-attempting to transfer without staff assistance, getting out of bed at night with disturbed sleeping patterns. No evidence of orthostatic hypotension at this time.

Resident in her room alone at time of incident, attempting to get up out of chair unassisted-wants to use bathroom, patient case study example. Gait unsteady and needs the assistance of one person for transfers, patient case study example. Resident ambulates in regular socks.

Roberts notified at pm. Mary Taylor, resident's daughter, was notified by telephone at 9 pm. Resident's status and immediate measures taken were explained to daughter. Daughter was reminded of her mother's care plan conference on Friday. P: To be determined based on further assessment and interdisciplinary evaluation. P was found on the floor in her room at pm this evening. P has been agitated and restless off and on since admission and has been showing signs of unsafe behavior-attempting to transfer without staff assistance, getting out of bed at night with disturbed sleeping patterns.

Resident in her room alone at time of fall, attempting to get up out of chair unassisted-wants to use bathroom. Gait slightly unsteady and needs the assistance of one person for transfers. Mary Taylor, resident's daughter, was notified by telephone at pm. Resident does not complain of pain and there is no evidence of grimacing or pain upon movement.

She has had no more falls. She is restless and agitated, especially at night. P: Increase staff surveillance of resident-monitor resident every 30 minutes, toilet every 2 hours or more frequently, ensure resident wears non-skid socks, use position change alarm while resident is up in chair or in bed.

Other interventions to be determined based on further assessment and interdisciplinary evaluation. Falls Assessment completed and discussed with falls team and family. Staff to increase surveillance patient case study example resident-monitor patient every 30 minutes, toilet every 2 hours or more frequently, patient case study example, ensure resident wears non-skid socks and use position change alarm while resident is up in chair or in bed.

Where was Mrs. P lying? What was she wearing on her feet? What clothes was she wearing? Was there anything next to her? What direction was she going? Was there enough light for her to see? Where was the call light? Was the bed locked into stable position? Where was her chair? Were any assistive devices present? After the second fall, patient case study example, where was the waist restraint?

Were the side rails up or down? Try to determine how she got out of the bed in spite of the restraint and bed rails. Was she wet or soiled? Was patient case study example confused or agitated? Was she in pain? What was her agenda? What did Mrs. P say happened? When was the last time she had been taken to the bathroom? When was her last food intake? P's falls. See the sample FAX Alert.

Communication to the resident's primary care provider will occur during the Falls Assessment process. Any one of the following would be appropriate as immediate interventions within the first 24 hours for Mrs. The 3-page fax should be sent to the primary care provider and the return orders should be received. The nurse should complete any orders and make the appropriate referrals. Behavior management strategies will be particularly important for staff to use with Mrs.

P because she has Alzheimer's disease and is confused, agitated and restless with unsafe behaviors. Particular emphasis should be on using a calm approach, simplifying the environment, patient case study example distraction when necessary, and providing comfort measures.

It is important to determine at least three things that bring Mrs. P comfort. An effort should be made to talk with her daughter and husband to discover what aspects of Mrs. P's home environment, culture, spirituality and work experience may be used to enhance her adjustment to the facility. Activities staff should offer appropriate daily activities for Mrs. As the Falls Assessment is completed and recommendations are received from the primary care provider, therapist and any other health care professionals, the nurse can select specific tasks on the Fall Interventions Plan.

Input from direct care staff as well as family members should be used to individualize the interventions. The nurse should monitor staff implementation of the interventions checked on the Fall Interventions Plan and record their effectiveness and any changes on the Fall Interventions Monitor.

The resident response should be monitored and used to determine effective approaches. Search ahrq. Latest available findings on quality of and access to health care. Funding Opportunity Announcements. Chapter 1. Introduction and Program Overview.

Chapter 2. Fall Response. Chapter 3. Chapter 4. Long Term Management. Chapter 5. Chapter 6. Environment and Equipment Safety. Appendix A. References and Equipment Sources, patient case study example. Appendix B.

Forms and Training Materials Appendix Contents.

 

 

patient case study example

 

Step Three—Record Circumstances, Patient Outcome and Staff Response. A Tracking Record for Improving Patient Safety (TRIPS) should be completed by the nurse in charge within 24 hours of Mrs. P's falls. A separate TRIPS form should be completed for each fall. See the sample TRIPS form. Step Four—FAX Alert to Primary Care Provider. Jan 01,  · The following case study illustrates the clinical role of advanced practice nurses in the management of a patient with type 2 diabetes. Case Presentation A.B. is a retired year-old man with a 5-year history of type 2 suljettfu.ga: Geralyn Spollett. The following is the assignment for which this sample case study presentation was written. Clinical Assignment 1: Written Case Presentation Choose a patient from your clinical experience and develop a written clinical case presentation. 1) Use a clinical decision-making process to present your patient, for example: a) SUBJECTIVE DATA.