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Reginald - a medical/surgical case study

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on 5 August 2013

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Transcript of Reginald - a medical/surgical case study

Reginald - 'Reg'
Referral
81 year old man
Admitted with bowel obstruction
Presenting condition
weight loss
decreased mobility
fatigue
abdominal pain
Past medical history
bowel cancer
hypertension
diabetes
osteoarthritis
a/w unilateral knee replacement
Medical Assessment:
Laparotomy including stoma formation
Currently:
day 4 post-op
transferring with WZF and AO2
not mobilising
needs assistance with personal care
new acute confusion
catheter in situ
assistance managing stoma
Information Gathering
Initial Assessment
Lives with wife in 1st floor flat with lift for access
Normally fully independent with all ADLs
Normally mobilises with 1 stick over short distances indoors
Has an electric scooter for outdoor mobility
Is a car driver
No other equipment in situ
Wife reports some short term memory loss
EMS = 0

Problem Identification
Laparotomy, Diabetes, Osteoarthritis, Hypertension

Pain, fatigue, confusion
81, missing wife, used to being independent
Cannot mobilise
Needs assistance to:
Complete transfers
Meet personal care needs
Manage care of stoma
Acute confusion and pre-morbid memory loss
Changes to toileting
Pain
Fatigue
Reduced independence and change of roles
Problem List
Goal Setting
1) To be independent with transfers using a WZF within 4 days

2) To be independent mobilising with a WZF out to the toilet (6m) within 7 days

3) To be independent washing upper body within 2 days

4) To complete basic stoma care following advice from stoma nurse
Personal care
Leisure
Action Plan
1) Work alongside physio and nursing staff to practice transfers and walking on daily basis

2) Liaise with doctors and potentially pain management team for appropriate pain relief

3) Liaise with stoma nurse for advice re: management of stoma

4) Functional wash and dress assessment including management of stoma

5) MOCA & potential referral to OPMH

6) Involvement of wife and potential diary to record advice and information


In hospital, confusion, disruption to sleep, change to routine
Ongoing assessment & revision of action
Day 8 post-op
1) Level of mobility is inconsistent due to pain and fatigue

2) Requires assistance of 1 to complete bed transfer

3) Occasionally independent with sit to stand from chair and toilet but this is also inconsistent

4) Able to wash and dress upper half and complete basic stoma care

5) EMS has improved, now scoring 6.

6) Has had TWOC, but is occasionally incontinent of urine

7) MDT have noticed improvement in cognition – appears less confused, MOCA score increased from 16-22 in 3 days

8) Wife visiting daily, ordering groceries in

Outcome
OT: recommends period of in-patient rehab as Reg is not back to baseline function but has further rehab potential


Reg: wants to return home as he misses his wife but realises he is not back to normal so will accept help
Wife: wishes Reg to return home but has some anxieties re: how they will cope
Discussion re: discharge
Reg to return home with TDS POC
to assist with:
bed transfers
washing and dressing lower half
toileting as required.

OT to provide:
wheelchair
Pressure relieving mattress
Pressure relieving cushions
Bed lever
WZF
Glideabout commode





Digestive system, cardiovascular system, mental functioning




Referrals to be made to:
District nurse
Continence nurse
Community rehab team
Early supported discharge
OT to provide information on:
Day centres
Domestic assistance
Long handled aides
Reg Example
1) Transferring with wheeled frame and help of two people
1) To transfer independently with wheeled frame within 4 days

2) To walk with wheeled frame approx. 6m within 7 days

3) To wash upper body independently within 2 days
Becky Coles
07/08/13
Review
Strengths
Weaknesses
Opportunities
Threats
Motivation of patient
Support of wife
Willingness to accept help
Met patient's goal of returning home
Home environment suitable
Pain & fatigue limiting participation in ADLs

Suitable community resources, can attend day centre
Involvement of MDT
Limited therapy resources
Wait for some MDT input
Infection
Future deterioration in mobility and functional ability following TKR
Full transcript