Read a Case study
then write SOAP note
Medications : must list the medications and dosages that the patient is on, along with any adherence to medication issues identified or potential patient education: must include medication teaching of at least one medication
Meet the Client: Leo WhiteLeo White, a 64-year-old male, was diagnosed with Parkinson’s disease 4 years ago. He has been married to his second wife, Nancy, for 10 years. Leo has 2 grown children who live out of state, and Nancy has one grown daughter who lives close by. Until recently, Leo and Nancy had always been active in the community. They attended church, played bridge, and enjoyed being with each other. Leo had been able to care for himself independently since his diagnosis, but he is now requiring more assistance with activities of daily living. He does not want to participate in any usual activities and just sits in his recliner. Leo was prescribed the antiparkinsonian medication carbidopa-levodopa (Sinemet) shortly after being diagnosed with Parkinson’s disease. Before starting the medication, the nurse in the healthcare provider’s office explained the action of Sinemet as part of medication teaching. Nancy calls the healthcare provider’s office and reports to the nurse that Leo has started seeing and talking to people that have been dead for many years. In addition, he has developed jerky movements of his head and has begun smacking his lips. Nancy brings Leo to the healthcare provider’s office. After assessing Leo, the healthcare provider informs Nancy that Leo is going to get progressively worse. Nancy starts crying and tells the healthcare provider she just can’t keep caring for Leo by herself. The healthcare provider writes a referral for home health care.
Home Health Nurse Visit
During the initial visit with the home health nurse, Nancy expresses frustration, stating that it is getting harder for her to understand what Leo is saying, although he can still communicate if she gives him enough time. In addition, the nurse observes that Leo has a shuffling gait and has difficulty getting out of the chair. Leo tells the nurse that he is starting to have difficulty eating and chokes when swallowing food. Because Leo walks with a shuffling gait and tends to lean forward when walking, the home health nurse discusses Leo’s continued weakness, mobility concerns, and safety issues with Nancy. Leo is concerned because he is having difficulty eating and bathing independently. He tells the nurse that he is worried about Nancy having to do everything for him and that he does not want to be a burden to her. Leo shares with the home health nurse that he fears he may become unable to make decisions for himself. He states that he wants Nancy to be able to make decisions for him. He is worried that his children will try to decide what is best for him and states that he does not want them making any decisions about his health care. Leo chooses to complete a Living Will, along with the Durable Power of Attorney for Health Care. The home health nurse obtains the needed documents. To complete the forms, Leo asks the home health nurse to serve as the witness while he signs them. The forms are signed, and then are witnessed by Leo’s next-door neighbor. The forms are placed in Nancy’s desk at home. Copies are sent to Leo’s children, Leo’s healthcare provider, and to the local medical center to be placed in Leo’s records.
Physiological Needs
The home health nurse visits Leo and Nancy’s home weekly. One week after the initial visit, Leo shares with the nurse that he has not had a bowel movement in 3 days. Nancy shares with the home health nurse that she doesn’t understand why Leo is getting constipated when he doesn’t eat very much. She tells the nurse that he is losing weight and his clothes are hanging off his body. The home health nurse tells Nancy that Leo’s medications, as well as his inactivity can cause constipation, no matter how little he is eating. The home health nurse is concerned about Leo’s constipation, lack of appetite, and weight loss.
A Complication Occurs
Two weeks later, Leo falls while walking from the living room to the bathroom, hitting his head on a coffee table. He is transported to the medical center and admitted to the medical floor for head injury observation and possible transient ischemic attack (TIA). Nancy calls the home health nurse to report what happened. When the home health nurse visits them in the hospital the next day, Nancy is crying and tells the nurse that she just can’t take care of Leo at home anymore. Nancy shares with the home health nurse that it is getting harder and harder to understand what Leo is trying to say, even when allowing more time. This is increasing the frustration level for both Leo and Nancy.
Referral
Nancy asks the home health nurse what “other people” do who have family members with Parkinson’s. She states, “I feel so alone in this.” The home health nurse recommends that Nancy attend a support group sponsored by the National Parkinson Foundation. Nancy attends a support group, where the nurse leader begins by explaining the disease. A visitor in the support group asks the nurse leader, “How does someone get Parkinson’s disease?”
At the end of the meeting, Nancy shares that she is angry because this is happening to her, and she feels guilty thinking about having to put her husband in a long-term care facility. Many of the group members share that they had to go through the same thing, and one woman shared that she put her husband in a facility just last week. After the meeting is adjourned, Nancy goes out for coffee with 3 of the group members.
Long-Term Care Placement
The nurse and social worker at the hospital discuss possible long-term care facilities with Nancy and Leo. Leo wants to be near home so Nancy can visit often. The social worker provides Nancy with the names of several nursing homes close to their home. Nancy expresses concern about how they will pay for the nursing home care. Later in the day, the primary nurse enters the room and observes Nancy sitting in the chair looking worried. Nancy shares with the nurse that she has no idea how to pick a nursing home for her husband.
Transfer to the Nursing Home
Three days later, Leo is transferred from the medical center to a long-term care facility near his and Nancy’s home. Leo is aware of where he is going and understands that this is the only reasonable option Nancy has available. Even though Nancy realizes that this is the best course of action, she is ambivalent and apprehensive about Leo going to the nursing home. She calls the home healthcare nurse and expresses her concern that the nursing home won’t take good care of Leo. Leo is in a semi-private room with a man who is alert and sitting in a recliner reading. After saying, “Hello” to Leo’s roommate, Nancy asks the admitting nurse, “What can I do to help make this transition easier on my husband?”
The primary nurse on the 7-3 shift is caring for six clients in addition to Leo.
The UAP assigned to assist Leo with personal hygiene gets frustrated because Leo is not moving as quickly as the UAP thinks he should. The primary nurse observes the UAP yelling at Leo that he needs to hurry up or he won’t be allowed to take a shower.
Gastrostomy Tube Insertion
Four days after being admitted to the long-term care facility, Leo experiences a choking incident during lunch that requires his transfer to the medical center. After evaluation by the healthcare provider and the speech therapist, a percutaneous endoscopic gastrostomy (PEG) tube for enteral formula feedings is recommended. The PEG tube is inserted without any complications. Leo is brought back to his room where Nancy is waiting at his bedside. The next morning Leo is started on a continuous enteral feeding at 25 mL/hr via a pump. Leo is placed in a semi-Fowler’s position.
Complications of Enteral Nutrition
Leo has been back at the nursing home for 3 weeks. He is becoming progressively weaker and has had several episodes of diarrhea, but he has not had any weight loss. The primary nurse is preparing to administer an intermittent enteral tube feeding of 480 mL over the next 6 hours.
The nurse is administering Leo’s 9:00 a.m. medications via the PEG tube. Leo’s medications include carbidopa-levodopa (Sinemet) scored tablet, benztropine mesylate (Cogentin) elixir, and a baby aspirin. After the nurse administers the medications, Leo has a large liquid stool. While the nurse and the UAP are changing the bed linens, Leo complains of cramps in his legs.
Hospice
Leo’s condition is deteriorating daily. He tells Nancy that he wants to die at home. Nancy tells the nurse about Leo’s request and tearfully says, “Someone told me that hospice care will allow me to take him home to die. Can Leo be on hospice care?”
Nancy calls the local hospice agency and requests information about hospice care.
Return Home
Nancy discusses Leo’s wishes with his healthcare provider. Since the healthcare provider believes that Leo’s prognosis is less than 6 months, a referral for hospice care is made. Leo is experiencing small strokes that are causing further deterioration, and he has signs of congestive heart failure. The hospice nurse comes to the nursing home to discuss the preparations for Leo’s transfer home. Nancy expresses concern about how she will pay for hospice care. Leo is alert and oriented enough to realize that he is going home. A hospital bed and bedside commode are delivered to the home, and the hospice nurse is waiting there to meet the ambulance when Leo arrives. The hospice nurse tells Nancy and Leo that they need to discuss an Out-of-Hospital Do-Not-Resuscitate Order (DNR).
Case Outcome
The hospice nurse performs the initial assessment, explains what will be done for Leo during this time, and leaves phone numbers in case Nancy or Leo have any questions.
One month has passed since Leo’s return, and he is happy to be home. The hospice nurse comes to visit Leo twice a week. The hospice volunteer visits twice a week to help Nancy with Leo’s activities of daily living and to allow Nancy to go shopping and have a few hours for herself. Nancy’s daughter comes over two to three times a week and helps care for Leo. Leo’s children are able to arrange to take Family Medical Leave to help with Leo’s care. With the help and support of hospice staff, Nancy, and the children, Leo should be able to spend his remaining days in the familiar surroundings of his home.