2.5: Case Studies

See Case Study Sample Forms for filled-out case study forms

Orthopedic

Mrs. Cora Connelly is an 83-year-old female who was recently hospitalized after falling at home, sustaining multiple fractures of the lower and upper extremities. She sustained a fracture of the right hip requiring a total hip replacement (THR), fracture of the left tibia which was casted and a right Colles’ fracture which also was casted.

Mrs. Connelly was transferred to ABC Rehab and Care Center for rehabilitation. Upon admission, she was NWB on the left lower extremity and was under total care as a result of low pain tolerance, right (dominant) hand being casted and limited mobility in the lower extremities.

Prior to hospitalization, Mrs. Connelly lived alone and was one year post a left hip fracture. She and her family felt that she was not safe enough to return home and therefore would be staying for long-term care.

Starting upon admission, Mrs. Connelly received Occupational and Physical Therapy.

Her discharge status was as follows:

• Limited assistance bed mobility from supine to sit.
• Limited assistance for transfers from bed to wheelchair and occasional extensive assistance for toilet transfers.
• Ambulates with platform walker and limited assistance for 40-50 feet. Much encouragement and reassurance are required as Mrs. Connelly expresses much fear of falling again.
• Independent with upper body dressing.
• Limited assistance needed with lower body dressing with adaptive equipment.
• Limited assistance needed with bathing in shower.
• Extensive assistance sometimes is needed with toileting.
• Flexion and abduction on the lower right extremity are 3+/5. Knee flexion and extension on lower left extremity are 4/5. Right wrist extension is 3-/5 and wrist flexion is 3+/5.
• Resident uses resting hand splint at night for wrist drop and has an exercise program to follow. CNAs have been trained to put on splint at night.

Goals for RNP

• Resident to ambulate 120 feet SBA with use of walker (e.g., walk to dining room and back.)
• Resident to transfer in/out of bed and on/off toilet with supervision.
• Bed mobility to supervised level.
• Resident to be pain free after exercises.
• Resident to tolerate hand splint at night without pressure or irritation.

RNP Plan of Care

• Ambulation three to five times per week with walker.
• Range of motion (ROM) and strengthening exercise program five times per week for lower extremities.
• Activities of daily living (ADL) program three times per week for lower body dressing.

Multiple Medical

Tessie Tripper is a 79-year-old female, 5-feet-4, weight 148 lbs (67.2 kg), with a history of DMII, macular degeneration, CHF, mild COPD and multiple DJD. She is eight years status post left THR (elective); her diabetes is controlled with diet alone. Daily medications include Celebrex, Xanax, Lotensin, a multi-vitamin with zinc and Senokot. She recently stopped taking Premarin after long-term use.

Mrs. Tripper’s husband died from complications of Alzheimer disease one year ago. She had been his primary caregiver. After her husband’s death, she sold her three-bedroom home and moved to an apartment on the advice of her daughter. After just six weeks in her apartment, Mrs. Tripper began to exhibit signs of confusion, phoning her daughter several times a day, buying more groceries than she could use and neglecting her housekeeping, hygiene and appearance. She left her apartment and moved in with her daughter and son-in-law and their two high-school-aged children. Her mental and physical condition improved quickly, although she frequently complained of fatigue and weakness in her left leg. Over the next several months she seemed to be adjusting to the busy household and even began going to church and socializing with friends (which she had not been able to do while caring for her husband).

Mrs. Tripper’s condition has now changed. Within the last three weeks she has fallen twice that she acknowledges, though her daughter believes that she may have fallen at least two more times when she was home alone. Her most recent fall resulted in a fracture of the left distal radius without any other apparent injuries. Her daughter, concerned for her mother’s safety, arranged for placement in an assistedliving facility where Mrs. Tripper stayed for only two days before complaining of chest pains and shortness of breath. She was admitted to acute care, observed for two days and discharged with a diagnosis of exacerbation of COPD. She apparently did not have a heart attack, but her Physician has recommended skilled-nursing care “until she gets her strength back”.

On admission to the SNF, Mrs. Tripper was alert and oriented, B/P 98/60, HR 104. She was screened by the Therapy Department, and it was determined that neither her diagnosis, hospital stay, nor functional status could support justification for Physical or Occupational Therapy. Despite the cast on her left forearm, she is independent with bed mobility, able to walk from her bed to the bathroom and requires only setup assistance with clothing management and grooming. She complains of fatigue and spends most of the day in bed.

Her daughter is willing to take Mrs. Tripper back to her home only if she is assured that her mother is able to walk independently (level surfaces and eight stairs) and care for herself.

Goals for RNP

• Increase functional out-of-bed tolerance to four hours.
• Restore safe, independent ambulation without assistive device, household level (flats and stairs.)
• Independent bathing, dressing and grooming.

RNP Plan of Care

• Supervised ambulation five times per week to resident’s tolerance.
• Routine exercise program five times per week for strengthening, balance and activity tolerance.
• ADL program five times per week for room- level ambulation and functional mobility.

Neurological

Mr. William Lowe is a 59-year-old male who came from a weeklong stay in an acute-care hospital secondary to dense CVA with right hemiparesis, dysphagia and aphasia. Prior medical history includes obesity, diabetes, COPD and arthritis.

Mr. Lowe was transferred to a skilled-nursing facility (SNF) for rehabilitation involving Physical Therapy, Occupational Therapy and Speech Therapy. Prior to the CVA Mr. Lowe had been independent at home, working as a truck driver and right-hand dominant. At the time of evaluation, he required maximum assist with bed mobility, sitting balance and transfers. He was nonambulatory. Right extremities were flaccid requiring max assist with upper- and lowerbody dressing. He also needed max assist with grooming, hygiene and feeding. He was non-verbal, following simple directions with max cueing and had a severe swallowing problem with pocketing of food on the right.

Mr. Lowe participated in PT, OT and Speech Therapy and was discharged at the following level of care:

• Minimum assist with bed mobility.
• Min assist transfers using the hemi-walker with step-pivot technique.
• Min assist ambulation with hemi-walker and right AFO up to 60 feet on level surfaces. Right leg drags some with gait. Increased assistance/cueing is needed as he will occasionally lose his balance in crowded environments. Resident experiences mild SOB with physical exertion.
• Mod assist with lower-body dressing.
• Min assist with upper-body dressing and set-up for grooming.
• Min assist for toileting and hygiene.
• Requires set-up in the dining room with plate guard and dycem in Restorative Dining Program.
• Right upper extremity is non-functional and requires a resting hand splint due to flexor tone and pain in right hand.
• Verbal communication consisting of “uh- huh,” “yeah” and “huh-uh” with fair accuracy.
• Auditory comprehension and understanding are limited to short sentences and phrases.
• Laryngeal excursion is good, Mr. Lowe is able to cough and clear, no overt signs of dysphagia with mechanical soft diet and nectar thick liquids.
• Swallow protocol includes alternating sips and bites, cueing to chew completely, swallow and clear mouth between bites and check for pocketing on the right.

Goals for RNP

• Resident to ambulate to and from the toilet and dining room.
• Maintain functional mobility and strength to allow for active participation in SNF activities.
• Prevent contractures and pressure sores.
• Safe and efficient swallow.

RNP Plan of Care

• Transfers and ambulation practice with hemi-walker with AFO while monitoring for SOB.
• Soak and range program for right upper extremity.
• Application of right resting splint and monitoring for redness and pressure.
• Restorative Dining Program with swallow protocol.

Dementia

Mrs. Ava Wave, a 73-year-old female, was diagnosed with Alzheimer disease about two years ago. Her neurologist told the family she appeared to be in the “middle stage” of the disease.

She has moderate problems with recent memory, although her immediate and remote memory are intact. She needs minimal help with dressing and personal hygiene. She feeds herself without difficulty but experienced a 15-pound weight loss, has become weak and has fallen without apparent injury.

Mrs. Wave is able to write at the sentence level and comprehends reading at the short paragraph level. She is showing increased difficulty with word finding and agitation regarding loneliness, complaining that “My son never calls me or comes to visit me,” despite daily visits and phone calls from the son.

She was admitted to SNF level as her spouse was no longer able to take care of her. She had been wandering in the neighborhood and getting lost, forgetting family names, phone numbers and addresses. She is also experiencing “sundowner’s syndrome,” has become combative and refuses to take her medication from her husband.

She was referred to Speech-Language Pathology by Physical Therapy, as she cannot remember strengthening exercises or to follow safety precautions while using assistive devices.

Nursing also reports the resident has refused to consume medication (“I already took them.”) In addition Mrs. Wave’s relationship with her spouse has deteriorated as functional daily communication has been reduced to minimal comments secondary to Ava Wave’s inability to recall the events of the day.

The Speech-Language Pathologist evaluated Mrs. Wave and recommended an assistive communicative device, with the RNA establishing consistency and use of memory cueing systems.

Goals for RNP

• Decrease agitation regarding her perception of visitation frequency using memory cuing system 100% of the time.
• Consume medication with confidence of timeliness using memory-cueing system 100 percent of the time.
• Follow set protocol established by PT using memory-cueing system with minimum cueing.
• Increase her ability to recall daily events to increase her functional communication using memory-cueing system.

RNP Plan of Care

• Calendar schedule of daily events for orientation.
• Visitor and medication log for daily occurrences.
• Hourly diary of activities.
• Personal information guide for ongoing reference.