preview

Mr Brown Case

Satisfactory Essays
Open Document

D/A: Mr. Brown had two appointments this week. On 02/06/17, Mr. Brown was transported to his appointment with Dr. Chua. According per Nurse Note, assessment states shortness of breath, coughing and tiredness. Consumer complained of pain, headache, back pain and arm pain. Consumer was assisted to his appointment with Dr. Redelcovecui in Dover at 2:42 p.m. On 02/08/17, according to the Nurse note, consumer was seen by Christiana Care Vising Nurse Associates for physical therapist evaluation. The Visiting Nurse stated that “consumer tolerated treatment well today.” Consumer met with his psychiatrist Dr. Capiro on02/06/17. Dr. Capiro provided consumer a comprehensive, psychiatric & medication review and an assessment of his needs. Consumer was …show more content…

Brown showered independently. On 02/05/17, Case Manager was helping Mr. Brown search for his missing cell phone when Case Manager came across a pack of Newport cigarette and a lighter. Case Manager took the pack of Newport Cigarette and light and placed it on Manager’s table. Case Manager warned Mr. Brown about the hazard of sneaking cigarette in his room, because of his oxygen gas and the implication smoking has on his health. Staff noted in the communication log that consumer showered twice on 02/05/17, the consumer diaper was covered in feces. Mr. Brown asked for Zofran medication at 7:30 p.m... Mr. Brown was prompted and assisted with personal care on 02/06/17. He was compliant. Mr. Brown refused to eat lunch on 02/06/17; staff encourage the consumer, but did not respond. On 02/08/17, staff noted in the communication log that if Mr. Brown did not have his proof of his divorce certificate by February 23; his Long Term Care application will be denied to move to a Nursing Home. On 02/08/17, when Mr. Brown was prompted to come out for his medication; it took him 15mins before coming out. Staff stated that on 02/09/17, Mr. Brown showered immediately when he returned from dialysis treatment at 4:50 p.m. Mr. Brown nose was bleeding while receiving his 5pm medication on 02/19/17; he reportedly told the Nurse that his nose has been bleeding for the past few weeks and staffs knew about his nose bleed. Jody a Nurse from Christina Care called concerning Mr. Brown medication. Jody stated that she will visit the following day at 8:00 am and would like to speak with the Nurse in charge of Mr. Brown’s medication. Mr. Brown showered independently in the morning on

Get Access
Related
Get Access