Client Information (SBAR, H&P) An 85-year-old woman with hypertension and hyperlipidemia presented with gradual and progressive cognitive impairment for more than 2 years, involving cognitive domains of memory, executive function, visuospatial and mood. She has short-term memory loss such as forgetting whether she has eaten or showered. She will also ask the same questions repeatedly. However, her long-term memory remains intact. She has forgotten how to cook and has recently burnt the pot while cooking on the stove. She is also unable to manage finances and absence of postural or rest tremors, normal limb power, tone and tendon reflexes. She has lower limb apraxia and mild postural instability. Her Mini-Mental State Examination (MMSE) was 16. While she scored 0 for delayed recall, she was able to recall all 3 objects with either category or lexical cueing. Main Concept (Should be focus of below map) Impaired memory CONCEPT MAP TEMPLATE: Recognizing Cues (S&S) Disease Process/Pathophysiology/Risk Factors Analyzing Cues/Conditions Generate Solutions/Outcomes/Interventions SMART Planning 2. 3. Evaluating Outcomes 3. 1. 2. 3. 5. Page 2 of 3 Prioritizing Hypotheses Taking Action-(How To) Page 3 of 3 NURSING PROCESS TEMPLATE: Assessment (Recognizing Cues) Which client information is relevant? What client data is most important? Which client information is of immediate concern? Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data. I Analysis (Analyzing Cues) Which client conditions are consistent with the cues? Do the cues support a particular client condition? What cues are a cause for concern? What other information would help to establish the significance of a cue? Analysis (Prioritizing Hypotheses) What explanations are most likely? What is the most serious explanation? What is the priority order for safe and effective care? In order of priority, identify the top 3 client conditions. Planning (Generate Solutions) What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning-specific, measurable, attainable, realistic/relevant, time-restricted-Goal setting) Subjective Data: Progressive cognitive decline over 2 years o Short-term memory loss (forgetting meals/shower) Repetitive questioning Inability to cook safely. Problems with financial management 。 Long-term memory intact Objective Data: © MMSE score: 16. Delayed recall score: 0 。 Positive response to category/lexical cucing Bradykinesia Lower limb apraxia Mild postural instability Hypertension and hyperlipidemia present Memory impairment patterns: ° Short-term memory significantly affected o Executive function compromised Visuospatial problems evident o Preserved long-term memory Intact recognition with cueing Clinical significance: Moderate cognitive impairment (MMSE 16) o Multiple safety risks identified 。 ADL performance compromised Financial vulnerability present Fall risk due to postural instability Additional information needed: Living situation Available support system Medication compliance Previous cognitive assessments 。 Family history Depression screening results 1. Risk for injury related to cognitive decline and unsafe cooking 2. Self-care deficit related to memory impairment 3. Risk for falls related to postural instability 1. Safety: Client will maintain safe environment with no cooking-related incidents within 1 week by 2. implementing safety measures Self-Care: Client will complete ADLs with assistance/reminders daily 3. Fall Prevention: Client will remain free from falls for the next month Interventions: Install safety devices in home (especially kitchen) Establish structured daily routine with reminders Arrange for supervision/assistance with meals . Set up medication management system Create environmental modifications for fall prevention 1. *Install automatic stove shut-off device Implementation (Take actions) 2. How should the intervention or combination of interventions be performed, requested, communicated, taught, etc.? What are the priority interventions? (Mark with asterisk) "Set up home care services for meal preparation and ADL assistance 3. "Create written/visual daily schedule Evaluation (Evaluating Outcomes) What signs point to improving/declining/unchanged status? What interventions were effective? Are there other interventions that could be more effective? Did the client's care outlook or status improve? 4. Arrange for financial management assistance 5. *Implement fall prevention measures . Frequency of safety incidents Completion of daily ADLS Fall occurrences Effectiveness of reminder systems Client's ability to follow schedule Family/caregiver feedback ⚫ Changes in cognitive status through regular MMSE Adequacy of support services Success indicators: . No safety incidents Improved ADL completion No falls Maintenance of current cognitive status • Client/family satisfaction with care plan

Client Information (SBAR, H&P) An 85-year-old woman with hypertension and hyperlipidemia presented with gradual and progressive cognitive impairment for more than 2 years, involving cognitive domains of memory, executive function, visuospatial and mood. She has short-term memory loss such as forgetting whether she has eaten or showered. She will also ask the same questions repeatedly. However, her long-term memory remains intact. She has forgotten how to cook and has recently burnt the pot while cooking on the stove. She is also unable to manage finances and absence of postural or rest tremors, normal limb power, tone and tendon reflexes. She has lower limb apraxia and mild postural instability. Her Mini-Mental State Examination (MMSE) was 16. While she scored 0 for delayed recall, she was able to recall all 3 objects with either category or lexical cueing. Main Concept (Should be focus of below map) Impaired memory CONCEPT MAP TEMPLATE: Recognizing Cues (S&S) Disease Process/Pathophysiology/Risk Factors Analyzing Cues/Conditions Generate Solutions/Outcomes/Interventions SMART Planning 2. 3. Evaluating Outcomes 3. 1. 2. 3. 5. Page 2 of 3 Prioritizing Hypotheses Taking Action-(How To) Page 3 of 3 NURSING PROCESS TEMPLATE: Assessment (Recognizing Cues) Which client information is relevant? What client data is most important? Which client information is of immediate concern? Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data. I Analysis (Analyzing Cues) Which client conditions are consistent with the cues? Do the cues support a particular client condition? What cues are a cause for concern? What other information would help to establish the significance of a cue? Analysis (Prioritizing Hypotheses) What explanations are most likely? What is the most serious explanation? What is the priority order for safe and effective care? In order of priority, identify the top 3 client conditions. Planning (Generate Solutions) What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning-specific, measurable, attainable, realistic/relevant, time-restricted-Goal setting) Subjective Data: Progressive cognitive decline over 2 years o Short-term memory loss (forgetting meals/shower) Repetitive questioning Inability to cook safely. Problems with financial management 。 Long-term memory intact Objective Data: © MMSE score: 16. Delayed recall score: 0 。 Positive response to category/lexical cucing Bradykinesia Lower limb apraxia Mild postural instability Hypertension and hyperlipidemia present Memory impairment patterns: ° Short-term memory significantly affected o Executive function compromised Visuospatial problems evident o Preserved long-term memory Intact recognition with cueing Clinical significance: Moderate cognitive impairment (MMSE 16) o Multiple safety risks identified 。 ADL performance compromised Financial vulnerability present Fall risk due to postural instability Additional information needed: Living situation Available support system Medication compliance Previous cognitive assessments 。 Family history Depression screening results 1. Risk for injury related to cognitive decline and unsafe cooking 2. Self-care deficit related to memory impairment 3. Risk for falls related to postural instability 1. Safety: Client will maintain safe environment with no cooking-related incidents within 1 week by 2. implementing safety measures Self-Care: Client will complete ADLs with assistance/reminders daily 3. Fall Prevention: Client will remain free from falls for the next month Interventions: Install safety devices in home (especially kitchen) Establish structured daily routine with reminders Arrange for supervision/assistance with meals . Set up medication management system Create environmental modifications for fall prevention 1. Install automatic stove shut-off device Implementation (Take actions) 2. How should the intervention or combination of interventions be performed, requested, communicated, taught, etc.? What are the priority interventions? (Mark with asterisk) "Set up home care services for meal preparation and ADL assistance 3. "Create written/visual daily schedule Evaluation (Evaluating Outcomes) What signs point to improving/declining/unchanged status? What interventions were effective? Are there other interventions that could be more effective? Did the client's care outlook or status improve? 4. Arrange for financial management assistance 5. Implement fall prevention measures . Frequency of safety incidents Completion of daily ADLS Fall occurrences Effectiveness of reminder systems Client's ability to follow schedule Family/caregiver feedback ⚫ Changes in cognitive status through regular MMSE Adequacy of support services Success indicators: . No safety incidents Improved ADL completion No falls Maintenance of current cognitive status • Client/family satisfaction with care plan

Comprehensive Medical Assisting: Administrative and Clinical Competencies (MindTap Course List)

6th Edition

ISBN:9781305964792

Author:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa

Publisher:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa

Chapter5: The Therapeutic Approach To The Patient With A Life-threatening Illness

Section: Chapter Questions

Problem 6CR

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