Reflection On Care Plan Of Care

He stopped working on March 1, 2013, the day of his injury. He has been working at his brother’s lawn mower repair shop. He basically comes and goes as he is able and is always paid $320 a week, regardless of how much time he spends at work. He has collected 26 weeks of Unemployment Insurance Benefits and was approved for Medicaid Disability with a $5,000 deductible every six months. He did not get Worker’s Compensation and has been denied Long Term Disability by his private insurer.

The patient is placed on Temporary Total Disability until October 17, 2016 at which time, he will be released to return to work without restrictions.

During this reporting period there have been no appointments to attend. Mr. Rife continues to work without any restrictions. He has pain to the left arm which he is tolerating until the surgery date on 5/3/17. The post operative appointment has not been scheduled yet. Mr. Rife wants to miss as little time as possible from

EMPLOYMENT UPDATE: Client is WECARE/FEDCAP exempt from work. Client submitted doctor note stating she cannot work due to medical problem.

On 10/2/17 I met Mr. McDoanld at the pain clinic in IINN. We met with Dr. Algahera. Mr. McDoanld reports and demonstrates shifting in positions due to pain. He reports he has right leg radiation at times. He continues to have trouble with sleeping and getting comfortable. Mr. McDoanld doesn’t want to take a narcotic pain medication. He is taking Flexeril at bedtime along with Motrin. Lidoderm will now be added to see if that helps with sleep. Mr. McDoanld also has a TENS Unit to use as needed. Dr. Algahera said Mr. McDoanld has 2 things going on. The compression of the disc and also a pinched nerve. He would recommend doing the Kyphoplasty first then moving on to epidural injections. Mr. McDoanld is being set up for an appointment

The pt. struggled to sit in the chair when meeting with the writer. The pt. was speaking very fast to the writer about his health concerns. Recently he attended his orthopedic surgeon to remove his stitches in his foot. His primary care doctor, Susan Daniels is referring him to an neurologist. His next appointment is the 28th on Thursday with Daniels. His therapy appointment with RVBH is Friday the 29th.

He still does have significant amount of residual back pain. Also, he does get still intermittent pain and numbness in the legs, left side worse than the right side. He also gets bilateral knee pain. He continues to have some bladder incontinence episode urgency. He does feel depressed as well. Treatments to date include anti-inflammatory medications, physical therapy, epidural injection performed in May 2015, spinal surgery in 2011, L4-L5 laminotomy with good improvement, and left L5-S1 laminotomy on 4/20/16 with improvement postoperative. Physical examination revealed that the patient has been able to discontinue the use of cane. There is pain to palpation over the L5-S1 area. Range of motion is limited. The patient has flexion of 60% of normal and extension of 40% of normal. Motor strength is 5-/5 in the left lower extremity, especially in the gastrocsoleus and extensor hallucis longus. Sensation is slightly diminished in the L5 distribution bilaterally, left worse than the right. Deep tendon reflexes is 2+ at the bilateral knee and 1 + at the bilateral ankle. Plan notes physical therapy of 2 x/ week to strengthen muscles, stabilize the spine and reduce pain; Flector patch 1.3% to be applied one patch to the back every 12 hours as necessary for

In my workplace, each resident has a personalized care plan. We speak to individual about his life, his family, wishes and preferences. We ask residents what they want, how they want it, who should be supporting them, etc. Then we put support in place to help them to achieve their goals, we help individuals find positive aspects in their lifes. To keep positive changes in place we must keep re-evaluating the individual wishes to keep their care plan up to date. The research shows that person-centred planning is associated with benefits for individuals and lead to positive changes in the areas of social networks, family, friends

On 4/25/17 I met Mr. Westenberg for his pr-operative teaching at the office of Dr. Cherwin. He was given a refill on his pain medication. He will be having blood work done on 4/26/17. Mr. Westenberg has been instructed on the use of the sling and what home exercises he needs to do after surgery. He asked about returning to work in 5 to 10 days. He was told that Dr. Cherwin will give him a work slip stating no use of the left arm. The post operative appointment will be 10 days after surgery. He will be given the date and time the day of his surgery.

On 6/13/17 I met Mr. Barta at the office of orthopedic surgeon Dr. Goethe. I was not allowed to go back into the examination room; I was told Dr. Goethe doesn't speak with case managers. He will fax dictation to me in about a week. I waited for Mr. Barta and spoke with him after he was seen. He was told he has 3 options. 1. Live with the shoulder pain, 2. Continue with physical therapy and try up to 3 cortisone injections to the shoulder, 3. Have surgery. If he has surgery the shoulder will never be 100%. Mr. Barta and his wife want to discuss the options then will call me and the doctor. There is no change in Mr. Barta’s work status per Dr. Goethe.

There have been no major changes in Mr. Dawkins’s pain level. Rebecca Berner RN CCM attended the scheduled pain management appointment on November 1, 2017. Mrs. Berner arrived at the pain clinic this morning at 10:00 am. Mr. Dawkins got there at 10:40 am. He was ambulatory and said his pain was about the same-primarily in his left shoulder. He could raise his left arm about 110 degrees and said it was better than before, but said he could not reach around to wash his back. He also indicated he completed all the pre-requisite testing to move forward with the surgery and wanted to know what the delay was. After an hour and a half, we were placed in an exam room and the medical assistant asked him why he had filled a script for Tylenol #4's.

I found this particular portfolio more challenging than previous ones. The main reason for this was the fact that I was the required to actively take part in the assessment, planning, implementation and evaluation of a patients care within the service. Doing this came with responsibility that I had not had in previous placements.

This portfolio entry requires an assessment and care plan to be presented incorporating the nursing process based on a client that I assisted in the care of during my clinical placement.

Isler completed her examination and reviewed the MRI and EMG. Dr. Isler informed Mr. Emm that she still recommends the injections and felt it was still his SI and arthritis. The physician continued physical therapy and the same work restrictions from the prior appointment. I inquired on massage therapy and Dr. Isler replied she did have this down for treatment. Dr. Isler clarified with Mr. Emm on if they were using a TENS unit and Mr. Emm replied they had and it seems to help a little. Dr. Isler recommended one for home use. I inquired about using tennis balls or medicine ball to desensitize the area. Dr. Isler that this was a good idea and recommended that therapist instruct Mr. Emm on the usage. Dr. Isler provided Mobic 15 mg by mouth one a day for the next 30 days. Mr. Emm replied he had Flexeril at home and had not been using it as he felt it played with is mind. A return appointment was scheduled for November 3, 2017 at 11:00 a

Tia nods, “think of a cream filled pastry. When you squeeze it too hard, all the cream in the inside comes out. The insides of that cushion, or disc, between your back bone is touching a nerve.” Jack goes to speak but Tia interrupts, “nerves are found everywhere in the body and help us sense things and perform movements”. Jack smiles half-heartedly. “When a nerve has any pressure on it, it can cause pain in the body. Those surgeries relieved that pressure, freeing up