home health nurse visiting an older couple in the community in order to assess the couple’s functional ability and the potential for their needing assistance with ADLs. Mr. and Mrs. Boyd are 72 and 67 years old, respectively, and have been married for 45 years. They have lived in the same neighborhood since Mr. Boyd retired from his bank manager job 12 years ago. Mrs. Boyd has been a housewife since their marriage. Mr. and Mrs. Boyd have one child, a son who lives in another city about 500 miles away. There are no other family members in their community. As you sit with both of them at the kitchen table, Mrs. Boyd tells you to direct all your questions to her because Mr. Boyd has trouble understanding questions. She goes on to explain that Mr. Boyd used to garden and maintain the yard but no longer seems interested in doing anything. He sleeps a great deal, seems to be eating less and has lost 10 pounds, He is often uncommunicative when she speaks to him. She says that her husband is getting quite forgetful, has received a diagnosis of early dementia and that this worries her because he was always socially engaging and a man who could speak on several subjects. Mrs. Boyd tells you that she makes all the decisions and spends most of her time planning meals, doing housework, and attending her ladies’ church group. She says that she could really use some help with outdoor tasks because these tasks had been handled by Mr. Boyd until just recently. When you ask what she means by “recently,” Mrs. Boyd replies that a change seems to have occurred within the last 6 months. You thank Mrs. Boyd for sharing this information with you, and you indicate that most of the questions can be directed to her but that you will be asking Mr. Boyd some questions as part of the assessment. Mrs. Boyd seems concerned by this but agrees to give you an opportunity to try and ask some questions of Mr. Boyd. You begin your assessment by asking Mr. Boyd about his ADLs, and clarifying the information with Mrs. Boyd. Mr. Boyd was unable to offer any additional information and seemed overwhelmed by the questions and began to cry. Mrs. Boyd added the additional information that Mr. Boyd needs help with all of his ADL’s, showering, getting dressed and brushing his teeth. He needs reminders to eat but eats poorly about a third of his meals. He has had 2 falls recently but was not hurt. He wandered out of the house and got lost a week ago. He does not complain about pain but does seem to be massaging his legs from time to time. He has a grimace on his face at this time. Mrs. Boyd begins to cry and hold Mr. Boyd’s hand. Once you have completed your assessment on Mr. Boyd use the information from the case study to complete your Basic Nursing Care Client Assessment, and the Pain and Morse Falls assessments.
Upon completion of your Assessments on Mr. Boyd, organize the data as if you were gathering it to enter on an EHR under assessment. Create an SBAR note on one of the problem you identified through your assessment (see sample and review chapters on documentation to be sure you remember how to do this) regarding needing to call the physician about the problem. Then create a nurses note inclusive of all of the problems that you identified and would document on the HER as a nurses note (review documentation chapter and ATI documentation to refresh how to do this). Lastly you will create a plan of care for one of your client’s problems by completing the concept map that uses the Nursing Process (Review the chapters on nursing process if needed to refresh). Identify the problem your patient has (ex. At risk for falling) by using the data (subjective and objective) that supports that this is a problem. You will need to set a specific, measurable outcome (goal) to achieve with a timeframe for when you will hope to achieve the goal. Find interventions (things you do to solve the problem) in your Perry and Potter textbook in the chapters that are relevant to the problem you identified for your patient (put the page # and source for the interventions you used) and then cite your full reference on the concept map. Evaluate what you would like to have happen if the interventions you chose worked out for your patient. This is a work alone and not a team assignment. Submit everything on canvas.