Case Presentation

Nicole Harlee
 Background Information
This resident is an older white female from Lumberton
She was diagnosed with congestive heart failure, has had
a minor stroke and some falls that have led her to receive
skilled nursing services
One of her strengths is with a lot of physical therapy she
is now able to do majority of her daily activities
independently.
Her biggest limitation is that she is so independent that
when it is time to call someone for help she chooses not to
and places herself at risk for falls.
 Background Information
One of her major goals from the assessment is to get more
involved in the activities that the facility offers, like bingo,
so she is not siting around thinking about her health all
day.
The intervention is planning a care plan meeting with the
resident and her family to come up with daily activities to
keep her going.
The resident plans on meeting this goal of getting more
involved in a months time.
 Questions
1. What are some biases you had going into the interview?
-This resident takes a lot of pride in being in the upper class, so walking in I
automatically thought she would feel like she was too good to talk to me.

2. What events or life experiences have shaped them into the person
they are?
-One of the main events that helped shape the resident into who she is
today is losing her husband to cancer when he was young and having to
raise 3 children on her own. She had to work many jobs and rely on
family support.
 Questions
3. What is the staff recommendation about diagnosis,
Interventions or treatment?
-Resident has a dx. of acute on chronic systolic congestive heart
failure. Staff recommends that this resident is constantly wearing her
oxygen due to shortness of breath and to watch the fatty and greasy
foods that she eats.

4. What were some value differences between you and the client?
-One of the biggest value differences between me and her was
religion. A value religion but she did not.
 Questions
5. What does research say on their diagnosis/problem/treatment?
-Research says the way to prevent progression is by monitoring
medicines that are taken and living a healthy lifestyle to avoid things like
future heart attacks.

6. What changes do recommend for the agency or service (Needs of

agency, changes, and rights issues)? Report those to supervisor.
-The resident feels like although the doctor and dietitian has given orders
not to eat certain foods the residents at that age should have the right to
choose what they do and do not agree with.
 Competencies/ Behaviors used
1: 1.2
2: 2.6, 2.7, 2.8
6: 6.17, 6.18
7: 7.19, 7.20, 7.21, 7.22
8: 8.23,