Millie Gardner, an 83-year-old female patient, is being discharged home today to the care of her...

Millie Gardner, an 83-year-old female patient, is being discharged home today to the care of her husband Fred (87 years old) following a 9-day hospitalization for pneumonia, dehydration, and failure to thrive. She has a history of hypertension (HTN), Type II Diabetes, and cerebral vascular accident (CVA) with left-sided weakness. Patient is alert and oriented but does have periods of forgetfulness during the overnight hours. Patient has intermittent incontinence of bowel and bladder and requires assistance with all activities of daily living (ADLs). Medications: Lopressor Lisinopril Plavix Metformin Novolin R per sliding scale *NEW* Multivitamin Colace Zithromax *NEW* Using the SBAR, please include the information that you will communicate to the physician's office at the completion of the visit?

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Expert Solution

Situation:

Hi. I am sending a patient Millie Gardner, 83 years old female. When she comes to visit, I want you to evaluate her and find out how she is managing with her activities of daily living. I am a bit concerned about her since she is having periods of forgetfulness.

Background:

She is has a history of hypertension, type 2 diabetes mellitus and cerebro-vascular accident with left sided weakness. She was recently hospitalized for 9 days for pneumonia, dehydration and failure to thrive.

Assessment:

Patient is alert and oriented, but has periods of forgetfulness during overnight hours. The patient needs assistance with activites of daily living and has intermittent incontinence of bowel and bladder.

Recommendations:

Medications prescribed- Zithromax, Colace and Multivitamin. To continue regular medications- Lisinopril, Lopressor for hypertension, Metformin, Novolin R as per sliding scale for diabetes mellitus, Plavix for cerebro vascular accident.

Nightingale answered 1 year ago

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