Scenario 1

Assessment Diagnosis Goal Interventio n Provide continent aids. Help with ADLS Skin integrity Nutritional chart Weight chart BGL Check 2 times a day Manage the confusion Personal hygiene Rationale Evaluation

79 old woman widowed from 6 months. Incontinent of urine and faeces No food at home

Actual -Dementia -disorientation -leg ulcer -Oedema -Diabetes

-Dignity -early recognitio n

Decrease the risk of infection

Physical assessment if the patient using toilet by self and frequency. Data collected from all the charts e.g.: weight chart, nutritional chart. Check the doctors notes and progress notes

appropriat

Disoriented to time and place Potential -depression Has infected leg -poor vision ulcer on her right leg -Neuropathy Both legs were grossly oedematous. Medical history of cardiac failure Leg ulcers and diabetes type II

e manageme nt

- UTI
-Malnutrition

-Help in orientatio n

-Decrease the accumulati on of fluid in leg.

Control the Oriented about weight time and place. Confirm the Provide glasses daily level of for better BGL vision Daily wound Urine analysis checkups if the wound is Monitor the healing dressing on the legs

manageme nt of diabetes, depression and poor vision.

Decrease

the risk of infection

-Personal hygiene

-Skin integrity

Scenario 2

Assessment

Diagnosis

Goal

Interventions

Rationale

Evaluation

MVA 1992 Minor head injury Rear end whiplash Difficulty with reading,followin g written instructions Decreased reading comprehension Poor concentration, Difficulty in phone communication. Wrong hearing of numbers Loses notes. Has SSDI for disability Chronic pain Tonsillectomy toxaemia Multiple falls Allergies : (From 15 to 20 years.) Sulfa-drugs Oranges Yeast Lactose Intolerant Molds, Gluten, Fermented products.

Head injury Rear end Whiplash Impaired cognition Suffering from chronic pain

Check the sign and symptoms Of dementia Personal safety Regular checkups Of Tonsils

Monitor BP in her sitting and lying position Help with mobility Help with daily activities Check the pain frequency(level) Put her on pain chart Regular checkups of tonsils Provide allergy free food and fluids

To check the pain level

Monitor the blood pressure if any cause of dizziness Walking chart and assistance require

Collect all information from all of charts that been started. Check the progress notes include doctors charts. Observation chart Collect the information from the physio. Changes in the allergic diet.

Tonsillectomy Toxaemia with first child. Regular blood High risk of pressure falls checkups Lots of allergies from different foods and other things. Dementia Impaired hearing

Pain relief Medication

Allergy free Physio foods. appointment Assess the Mobility Change of meals because of allergy

Change the diet pattern No perfumes to be given. assessmen t and help in hearing

perfumes

Assessment Diagnosis M.O 87 Year old female Lives alone Found crouched in corner Daughter visit Every three days Cut to L) eyebrow Cut lip Not able to answer the question Decreased skin turgor GCS 13 Knees Replacement Afraid from socialization Insomnia

Goal Avoid the day time napping Reduce the pain level

Interventions Assessment on sleep and behaviour pattern

Rationale To get the proper and on time sleep

Evaluation Check the all the assessment that been started

Complaining Pain in R) Shoulder,Fin ger joint Bilateral knees Bilateral knee replacement pain increases in supine position Spinal pain problem L side of chest and L breast region after Surgery in 1992 Macular degeneration And glaucoma postural hypotension High risk of fall

Recommend the pain relief and Pain put on pain management Check the assessment assessment form Confirm the and forms Keep pain causes Education about taking tablet if its the pain effective if management and laying not stop position needs after to be review discuss with the doctor

Recheck up with doctor about the knees