Your case mangement review will provide a detailed evaluation of the provision and coordination of care for one older client (80 years plus who has, cognitive impairment mixed Alzheimer’s, 2nd Fall to Parkinsons, AF, HT, CCF, T2DM, Dyslipidemia, etc) with whom you have worked during your clinical placement.
Yourreviewshouldaddressthefollowingpoints:
1. Introductionof yourclient.
Ensure both the person and the organisation have been identified.
2. Outcomesofacomprehensivehealthassessment
Youneedtoassessyourclientusinganappropriateframework.PleaseusetheprovidedNursingAssessmentFrameworktocollectdata(thisisnotincludedinthewordcount):conductaninterview,performphysicalexaminations andreviewrelevantdocumentation.TheNursingAssessmentFrameworkmaybecompletedelectronicallyorbyhand.Ifhandwritten,pleaseensureitislegible.
HandwrittendocumentswillneedtobescannedforelectronicsubmissionwiththeCaseManagementReview.
ThecompletedNursingAssessmentFrameworkmustbeattachedtoyourCaseManagementReviewsubmission.
3. Pathologicalchanges(symptompresentationandimpacton yourclient)
Selectthemainconditionthatrepresentsapriorityforthisclient(e.g.relatedtocurrentadmissiontoacutecare,reasonforadmissiontoresidentialfacility).Youneedtodiscusstheimpactof pathologicalchangesontheolderpersonandtheirfunctioning.
4. Nursingcareneeds:
- Medication
Discussyour client withregardtotheirmedicationandthenursingcare
involvedinadministration.
Considerissues(as relevant)suchas:
- over the counter (OTC) medications,
- polypharmacy,
- time of administration
- route of administration
- requirements to ‘crush’
Supportyourdiscussionwithrelevantliterature.
b. Coordinationandmanagementofyourclient’scare
- Mentalhealthissues
- Skincare: identifying patients/residentsatriskandpreventionofpressureinjuries
- Nutrition
- Incontinence
- Prevention of functionaldecline
- Confusion/delirium
- Falls
- Sleepandrest
- Pain
Selecttwo(2)oftheaboveareasthatarerelevanttoyourclientandreview(evaluate)thecoordinationandmanagementoftheircareunderthefollowingheadings:
a) Assessment
Reviewareassuchas:
- Risk/assessment scales provided by the facility
- Frequency of assessment
- Risk rating as identified by assessment tool
b) Actions/preventivemeasures
Discusscareactuallydeliveredanddocumented.
c) Actualoutcomes
Evaluatecareoutcomesforyourclient.
d) Analysisofevidence
Evaluatequalityofcaredelivered;e.g. wasthecaregivenaccordingtothepoliciesof thefacilityandevidencebased?
c. Involvement oftheinterdisciplinaryteam
Discusstheinvolvementof theinterdisciplinaryteaminrelationtoyourclient.
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