Lenore Anderson is an 83 year old widow and mother to Janet and James. James lives locally with his young family, and Janet lives on the South Coast some 400km away. James is the ‘person responsible’ for making health care decisions. Lenore was a music teacher and was married to Doug for 59 years until his sudden death two and a half years ago. Since then, she has struggled to live independently and has had depression and significant cognitive decline. She recently experienced a fall resulting in a fractured left humerus and admission to hospital. Lenore was discharged from hospital back to Clearview two weeks ago. She has a number of comorbid health conditions including peripheral vascular disease, hypertension, chronic renal failure and osteoporosis, involving her cervical and thoracic spine.

Trigger:

Return to RACF following discharge from hospital.

Assessments:

Screening for depression, pain, constipation. Wound review, Physiotherapist assesses her back pain and her balance and mobility.

Attendance:

• Lenore and James
• Physiotherapist to provide information on functional changes
• RN to provide information on assessments of wounds, pain and constipation
• GP via telephone to ensure consistency of information regarding clinical condition.

Key discussion points:

It is identified that pain associated with her back, fractured arm and leg ulcers may be affecting her appetite and resulting in agitation and distress. Although Lenore can communicate she often does not remember to ask for pain medication. Strategies for identifying when Lenore is in pain are discussed and a pain medication regime developed. The risk of constipation is discussed and preventative medication and bowel monitoring is commenced.

Discussion about the persistence of leg ulcers and ongoing oedema prompt the GP to consider a review of the cause of her ulcers, and of her cardiac medications. A trial of antidepressants is also agreed upon to determine the extent that depression is contributing to her current condition.

Outcomes:

• Medical review and possibly new treatment of underlying cardiac condition
• Trial of antidepressants
• Update of care plan indicating new pain management and bowel care regime.

Last updated 05 December 2015