CASE STUDY

By Lauren-Eve

CASE STUDY
Assessment : Coordination of Care completed Discharge Planning Assessment,
physician completed physical examination.
Conceptual Framework : Person-in-Environment and Maslows Hierarchy of Needs.
Background Information : Patient is a 68-year-old white female, who resides in a
skilled nursing facility. Patient has a history of Systemic Lupus Erythematosus,
Chronic Obstructive Pulmonary Disease, Hypertension, Bipolar Disorder,
Cerebrovascular Accident with residual left-sided hemiparesis, Irritable Bowel
Syndrome, Gastroesophageal Reflux Disease.

CASE STUDY
Background Information contd : Patient has a previous history of tobacco use, quit
11/2012, previous history of alcohol use, denies dependency. Patient has
multiple drug allergies. Patient is bedbound and dependent in ADLs, also able
to use patient call light/express needs. Patient admitted for bowel obstruction.
Services : Coordination of Care completed D/C Planning Assessment, completes
D/C Planning Progress Notes, D/C Note, completes D/C packet, orders durable
medical equipment, arranges certain appointments. This patient did not need any
DME upon discharge. This patient did have follow-up appointments with her primary
care provider (PCP). Life Link transportation was arranged.

CASE STUDY
Strengths and Limitations, of patient : Patient is alert and oriented x 3. Patient has a
family support system and has family that is local. Patient is able to express
needs/pain. Patient is bedbound with declining health.
Strengths and Limitations, of facility : Cape Fear Valley Medical Center is patientcentered in the approach to health care. Patient insurance (or lack of) may
dictate the types of services a patient may use. Patient following medical
advice/keeping appointments.

CASE STUDY
Assessment Goals : Coordination of Care is responsible for completing Discharge
Planning Assessment which allows case manager to identify potential needs
the patient may have and will allow for case manager to assess the type of
environment patient lives in (which in turn will aid in identifying potential needs).
Coordination of Care, Physical/Occupational/Speech Therapy and Nursing work
together to ensure patient health goals are met and patient is prepared with
equipment/appointments/placement for a safe discharge.

CASE STUDY
Biases :Knowing this patient personally and knowing her diagnosis of Bipolar
I was apprehensive about interviewing patient.

Disorder

Value differences :
Life-changing experiences : The patients life changed drastically following her stroke.
Her entire life-style has changed, she is dependent on others for
meeting needs.
Recommendations : Exploratory preformed, calorie count, nasogastric tube placed.

CASE STUDY
Ileus : Blockage of the intestines, caused by lack of peristalsis.
Peristalsis : Contraction and relaxation of muscles.
Causes : Abdominal surgery, pelvic surgery, infection, medications, muscle/nerve
disorders, adhesions.
Complications : Tissue death, infection.
Treatment : Surgery.

CASE STUDY
Problem Statement : How can patient be made medically stable for discharge.
Interventions : No interventions from Coordination of Care. Coordination of Care
arranged patient discharge and transportation when patient was medically
stable for discharge back to facility.

Changes : No recommended changes for agency or services. Facility is a hospital,

which is an acute care setting.

CASE STUDY
Information on this patient was obtained through Valleylink and Midas, which are
computer programs used to access patient information.
Information on this patient was also gathered through personal communication with
patient.