CASE PRESENTATION

COLLEEN LOCKLEAR
10/18/17
 BACKGROUND INFORMATION

African American female

75 years old
She has been in the facility since 2009 (8 years)
She has 2 children (son/daughter)
She is a widow
Previously lived in New York
College graduate
Worked with home health services for 34 years after
moving to North Carolina in 1981
 PROBLEM STATEMENT

Although she can feed herself, and get in a

wheelchair with assistance, she cannot walk or
wash herself. She was placed in this facility for long
term care because she has a number of health
issues.
Gout
Acute kidney failure
Muscle weakness
Chest pain
 SERVICES

She use to be followed by PT/OT therapy, but now

that she cannot walk, she no longer has therapy
services.
 STRENGTHS/LIMITATIONS

A strength the resident said she had in the past was

the ability to do math. Now that she is in a rest
home she said her strength is communication. She
loves to interact with others and have visits with her
family and friends. When she was younger she said
I dont think I had limits, I was happy working in the
health field. Now she is limited with her mobility
because she doesnt get up to walk. She is able to
feed herself, but she is dependent on someone
washing her and dressing her.
 ASSESSMENT GOALS

The goal for her assessment is to improve her mood,

thoughts, and ideas. When doing a interview we
look for their answers to change for the better when
asked how their appetite is and if they are
depressed.
 INTERVENTIONS

There arent any interventions in place for this

resident at this time.
If she would ever decide she wanted to go to
another facility or become a DNR patient at any
time, the MDS coordinator, administrator, social
worker, and director of nursing would hold a
meeting.
The meeting is an intervention of some type which
would include the family member(s) involved.
 BIASES I HAD GOING INTO THE
INTERVIEW
I didnt have any biases going into the interview
because I had talked to this resident several times
before. She is very pleasant and easy to talk to so I
was sure she wouldn't mind answering my questions.
 VALUE DIFFERENCES BETWEEN THE
CLIENT AND I
The client and I had the same values when it came
to work because she went to college and pursued
a career and I am doing the same.
She values family as well as I do; she enjoys visits
with her family and friends.
 WHAT EVENTS/LIFE EXPERIENCES
MADE THEM WHO THEY ARE?
Living in New York until she was 39 years of age was
a good opportunity for her career wise because its
such a big city. She said she loved going to school
there and working there but she moved to be
closer to her family.
She chose the health field because her mom was
sick while she was in school. She wanted to provide
a better life for those who cannot help themselves.
She worked in the health field all her life until she
retired.
 RECOMMENDATION ABOUT
DIAGNOSIS/INTERVENTION/TREATMENT
It is recommended in her treatment to include skin
checks daily. Because she is in bed for so many
hours a day. She is turned in the bed every 2 hours
so that skin breakdown or sores do not appear.
Also she is given several medications for her gout,
kidney failure, muscle weakness, and chest pain as
needed.
The nurses intervene if she tries to refuse
medications and ensure her that what they are
giving her is to help her. They cannot make her take
medicine but they will educate her the best they
can on what the medicine does.
 RESEARCH ON
DIAGNOSIS/PROBLEM/TREATMENT
Gout is a disease in which defective metabolism of uric
acid causes arthritis, especially in the smaller bones of
the feet, deposition of chalkstones, and episodes of
acute pain. Treatment is anti-inflammatory medicine.
Acute kidney failure is the rapid breakdown of kidney
functions that occurs when high levels of uremic toxins
(waste products of the body's metabolism) accumulate
in the blood. Treatment can include therapy, medicine,
a specific diet, and electrolytes such as potassium,
sodium, and calcium.
COMPETENCIES/BEHAVIORS USED

Competencies: 1, 2, 4, 6, 7
Behaviors: 1.1, 1.2, 1.3, 1.4, 1.5, 2.2, 2.3, 4.1, 4.2, 6.1,
6.2, 7.1, 7.2, 7.3, 7.4