Products Care Planning
Book of Summaries for Adult Day Care- Sample
Example 12
Participant with diagnosis of: hypertension, S/P CVA with L sided hemiparisis, urinary and bowel incontinence.
Complicating factors: Safety issues related to being home alone all day, caregiver difficulties, medication management, bedsore, very high risk for institutionalization.
Participant is a 62-year-old male with diagnosis of hypertension, S/P CVA with L sided hemiparisis and urinary incontinence. Participant lives with his wife who is his primary caregiver, but who works outside of the home in the morning four hours a day M-F. During this time participant is left home alone, with a neighbor who checks on him occasionally. Participant’s wife states that she is emotionally and physically exhausted, as she is the only one who provides assistance for participant’s ADL’s including the heavy lifting required for transferring, toileting and dressing participant. She receives little help from her children, who are encouraging her to place participant in a nursing home and “get on with her life”. Participant is confined to a wheel chair and requires max. assistance with the following ADL’s, dressing, bathing, transferring and toileting. Participant is unable to provide for himself transportation, cooking, laundry, housekeeping or shopping. Participant requires mod. assist with medication management, use of telephone, and grooming. Participant is able to make his needs known, yet his speech is halting and slurred. He often has word finding difficulties. His wife states that he received three sessions with the speech therapist only. Participant is at high risk for infection due to urinary and bowel incontinence, currently he suffers from a stage 1 bedsore on two areas of his buttocks. Participant appears to be a good candidate for bladder and bowel retraining. Participant has a good attitude and has expressed high motivation for engaging in program, especially PT and OT. It appears that participant received very little therapies following CVA, and has a high potential for improvement. Participant is at very high risk for institutionalization long-term in the SNF. We are asking for 5 days a week in order to help ensure participant is not prematurely institutionalized.