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Comprehensive Geriatric Patient Profiles and Treatment Plans. A report summary
Student’s Name
Institutional Affiliation
Course Name and Number
Instructor’s Name
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Comprehensive Geriatric Patient Profiles and Treatment Plans. A report summary
Age: 91 Years
Gender: F
Chief Complaint: Follow-up for generalized skin rashes, advanced dementia, psychosis, and other chronic conditions.
Plan of Care:
The 91-year-old patient had a 30-day follow-up appointment. With an oxygen saturation level of 96% and a blood pressure measurement of 122/67 mmHg, vital signs were steady. During the physical examination, the patient presented with a rash that extended from the back of the neck to both legs, arms, and face. Some people have reported seeing dry, round, scaly, discoloured skin patches. Generalized rashes and patches on the body as a result of inadequate skin care, advanced dementia, psychosis, abuse history, refusal to comply with ADLs, falling multiple times, unusual loss of weight, ulcerative colitis (K51.9), chronic pityriasis versicolor (B36.0), and overall weakness were all diagnosed.
The patient’s prescription history was meticulously checked when the treatment plan was made up, and the patient was urged to follow closely the advice about taking the antianxiety medicine and taking care of the skin every day. The Conversations regarding the patient’s condition should be made with the primary nurse in place, and fall precautions should be strictly followed. Apart from that, applying lotion on the patient’s face provided first aid in treating rashes. Immediate skin wound care, decline of cognitive function, fall risk, and weight loss were the key issues to consider for this old patient who has several underlying diseases.
CPT/ICD-10: 99307; F03.90
Age: 91 Years
Gender: F
Chief Complaint: Follow-up for osteoarthritis, newly diagnosed Parkinson’s disease, and other chronic conditions.
Plan of Care:
A 91-year-old patient’s main complaint during the 30-day checkup is a sore left finger. Osteoarthritis, the most common cause of arthritis, is suspected by the doctor. According to the measurements, the patient’s vital signs were steady, with 94% oxygen saturation and 110/61 mmHg blood pressure throughout the assessment. The patient’s right eye and whites were fuzzy when palpated, although they were improving. The patient had osteoarthritis (M19.9), cerebrovascular accidents, ambulatory impairment, essential hypertension, general weakness, an artificial right eye, and hyperlipidemia (E78.5), according to the diagnostic analysis.
The patient’s treatment plan and medications must be assessed as part of the therapeutic approach. The recommendation was to maintain the practice while taking Tylenol for arthritic joint pain. In potentially dangerous situations, the person should continue their routine physiotherapy and occupational therapy sessions, follow all safety regulations, and use these safety measures. The patient would evaluate the team and discuss their development as part of the process. My anxiety was secondary to the comorbidities in this aged patient; pain treatment requirements were crucial.
Age: 61 Years
Gender: M
Chief Complaint: Follow-up for abnormal weight gain, DMII, and other chronic conditions.
Plan of Care:
The patient, who was 61 years old and was in a wheelchair, came back for the follow-up thirty days after the first visit and a simultaneous one on excessive weight gain, plus the one ten days after that for diabetes mellitus type 2. For the observation of vital signs, blood pressure readings of 128/80 mmHg had been done, and BMI indicated that the patient was obese with a BMI of 37.15. The patient was diagnosed not as having one but rather many diagnoses; these included an unbalanced condition in weight, type 2 diabetes mellitus (E11.9), obesity, mental retardation, bipolar disorder, a closed head injury, and previous episodes of depression.
The treatment plan, which needed to be developed through the analysis of the present and effective plan and the current medications, was the main objective of the holistic nursing care I planned to implement. The psychiatrist remarked that it may be a good idea to maintain the same action plan and adjust the dosage accordingly to avoid fears of adding weight if needed. In addition to talking about the case with the senior nurse, it was also recommended that I keep close details about the patient’s weight. Besides that, considering the psychiatrist could be there for the management of medication part was also one of my plans. The weight management of this patient, as well as the exact control of diabetes and the treatments of mental comorbidities, were the significant issues addressed in the case.
CPT/ICD-10: 99307; E66.9
Age: 94 Years
Gender: F
Chief Complaint: 30-day follow-up
Plan of Care:
A follow-up appointment was scheduled for this 94-year-old patient after 30 days had passed. His heart and respiration rates were normal, and he denied feeling anxious. Those who had allergic reactions might trace it back to tomatoes and aspirin. No major concerns were found throughout the assessment, and the patient was also noted to be awake and oriented on two consecutive occasions. The following medical conditions were identified as diagnoses: orthostatic hypotension, a fall history, schizophrenia, dementia, severe depression, GERD (K21.9), polyarthritis, hypertension (I10), and others.
Several parts of the strategy were to keep going with the present plan, discuss it with the main nurse, analyze the patient’s care and prescription plans, and consider the patient’s restricted decision-making ability. Fall risk, cognitive impairment, mental comorbidities, and persistent diseases were the primary concerns of this older patient.
CPT/ICD-10: 99307; I95.1
Age: 81 Years
Gender: F
Chief Complaint: Follow-up after fall with no injuries, acute CHF, influenza exposure.
Plan of Care:
Asymptomatic influenza exposure, treatment of acute compensated congestive heart failure, and a follow-up appointment after a fall in an 81-year-old female patient were all reasons for the patient’s recurrence. The patient’s vital signs were a steady 125/74 mmHg blood pressure, 99 bpm heart rate, and 96% oxygen saturation level. A little soreness in the left rib cage was detected during the physical examination, but no soreness in the left hip region. Among the patient’s medical history were the following conditions: hyperlipidemia (E78.5), a history of rheumatoid arthritis (M06.9), essential hypertension (E07.5), acute renal failure (ARF), asymptomatic urinary tract infection (UTI), and managed atrial fibrillation (ATF).
Withdrawal of Lasix and ASA was a part of the treatment plan, which involved re-evaluation of their current approach to care, with an emphasis on including and removing certain medications. Regularly adhering to these safety guidelines, including physical and occupational therapy sessions, is the supplement of reasonable care. The strategy was centered not only on dialogues with the personnel but also focused on the patient’s health. The primary patient’s problems, such as tripping due to fall risk, heart failure, safety, and polypharmacy, accompanied by the patient’s multi-comorbidities, are the woes of that old patient.
CPT/ICD-10: 99307; R29.6
Age: 72 Years
Gender: M
Chief Complaint: Follow-up for nausea/vomiting, status post fall
Plan of Care:
This 72-year-old male patient came in for a follow-up appointment after experiencing morning sickness and vomiting after a recent fall. Consistent with obesity, the patient’s vital signs were steady; nevertheless, their blood pressure was 159/77 mmHg, and their body mass index (BMI) was 38.70. The patient, who was using the laxative lactulose, had not had a bowel movement in two days. Upon palpation, the physical examination indicated discomfort in the right bottom quadrant. The patient’s medical history includes the following conditions: obesity, hypertension, hyperlipidemia, known coronary artery disease (CAD), right lower quadrant pain, status post fall, status post right femur open reduction internal fixation with plate fixation, Pseudomonas wound infection, hyperglycemia, urinary retention (on Foley catheter), hypertension, hyperlipidemia, and a history of coronary artery bypass graft (CABG) surgery.
The patient’s present course of therapy was maintained, while a thorough evaluation of their medical records was conducted as part of the treatment plan. The patient was instructed to follow a clear liquid diet for 24 hours and have a KUB radiographic scan. The strategy also included continuing physical and occupational therapy and administering an enema and senna laxative as required. The plan acknowledged the patient’s moderate care demands and difficult medical decision-making and suggested staff discussions. They were managing the patient’s various comorbidities, caring for wounds, diabetes, danger of falls, and constipation.
CPT/ICD-10: 99307; K59.00
Age: 56 Years
Gender: M
Chief Complaint: New admission with complex cardiac/respiratory history
Plan of Care:
Acute coronary artery disease (I25.10) status post-CABG x3, respiratory failure with multiple intubations/tracheostomy, acute kidney injury (resolved), bilateral great toe amputations, and non-healing bilateral lower extremity heel wounds were among the complex medical conditions that this 56-year-old male patient presented with. He was a new admission into the hospital. The patient underwent a coronary artery bypass grafting (CABG) x3 treatment not too long ago, and there was a need for cardiac clearance for impending vascular procedures. Among the diagnoses that were made were coronary artery disease (CAD), acute on chronic respiratory failure with hypoxia (J96.21), anaemia, cardiac arrhythmia, diabetes mellitus (E11.9), dyslipidemia, history of deep vein thrombosis (DVT), hyperlipidemia (E78.5), non-healing heel wounds, non-ST-elevation myocardial infarction (I21.4), peripheral arterial disease (I73.9), status post coronary artery bypass x3, and many wounds.
As part of the plan, the patient’s medical records were reviewed, the current plan of care was maintained, tracheostomy care was administered, follow-up appointments were scheduled with the wound team, cardiologist, and pulmonologist, physical, occupational, and speech therapy evaluations and treatments were issued, and staff members were consulted. Considerations of this patient’s severe cardiac and respiratory difficulties, wound care, and rehabilitation requirements were among the most important considerations.
CPT/ICD-10: 99326; I25.10
Age: 75 Years
Gender: F
Chief Complaint: Follow-up for chronic disease management after ER visit
Plan of Care:
A 75-year-old lady was being interviewed for the reappraisal of her treatment concerning a chronic disease. The situation of her illness, which started with the fainting, shortness of breath, and coughing incidents after some minutes, alerted her to come to the emergency room. It was on the evaluation that she had a deep vein thrombosis (DVT) in her right lower leg, and wouldn’t it be more accurate to term her condition as ‘PE on DVT’? The blood pressure measured 126/70, with an oxygen saturation of 95%, and this remained stable during the physical exam. Anaphylactic reactions to hydrocodone and oxycodone follow the occurrence. One of the diagnoses was Diabetes 11.9, hypertension I10, DVT right-sided DVT, Acute Respiratory Failure, Hypoxia, and Bilateral pulmonary embolisms.
This plan features the record review, adding Eliquis to the treatment regimen continuation of physical and occupational therapy. Moreover, it involves safety protocol and has a timeframe that is meant to be 45 minutes for individual records, evaluation, documentation, and coordination of the care plan. It was the essence of my caring to effectively deal with this patient’s recent pulmonary embolism, DVT, respiratory distress, and chronic health conditions while providing necessary care.
CPT/ICD-10: 99307; I26.99
Age: 95 Years
Gender: F
Chief Complaint: New admission after treatment for pneumonia and CHF
Plan of Care:
The patient, a 95-year-old female who had acute diastolic congestive heart failure after taking antibiotics for pneumonia symptoms (J15.9) and shortness of breath, was referred to an outpatient clinic. Throughout cardiology PT/OT, she was able to get stronger and continue to the next step. The patient showed no agitation or unsteadiness, indicating a pleasant experience. Lungs affected (bronchial pneumonia) on both sides of the chest, high blood pressure (I10), heart failure (I50.9), elevated serum lipids (E78.5), chronic obstructive pulmonary disease (COPD) (J44.9), depression (J44.9), appendectomy in the past, and chronic kidney disease (N.
The plan included going over the patient’s medical history, keeping up with the current treatment plan (which provides for Lasix), evaluating and treating the patient through physical and occupational therapy, reviewing and completing the MOLST with the patient and her daughter, following up with the cardiologist, talking to staff, and recognizing the high level of complexity in medical decision-making, which includes reviewing medications, writing up assessments, and documenting care. The management of the patient’s respiratory and cardiac comorbidities, as well as their rehabilitation requirements and treatment objectives, were of utmost importance.
CPT/ICD-10: 99326; J15.9
Age: 75 Years
Gender: F
Chief Complaint: New admission after COVID-19 infection
Plan of Care:
After coming to the emergency room with symptoms such as shortness of breath, dry cough, raised fever, and tachycardia, the 75-year-old female patient was admitted to the hospital. She tested positive for COVID-19 (U07.1). Admitted for further rehabilitation, she underwent treatment. The patient’s vitals were steady, showing a blood pressure of 137/71 and an oxygen saturation level of 97%. Notable cases of allergies were reported to tetracycline, home dust, and Seprafilm. Included in the list of diagnoses were COVID-19, essential hypertension (I10), chronic atrial fibrillation (on Eliquis), neuropathy, managed asthma, history of seizure condition, anxiety disorder, significant depression, and bilateral mastectomy.
Reviewing medical records, maintaining the current course of treatment (which includes antidepressants bupropion and trazodone), consulting with mental health professionals for follow-up, evaluating and treating the patient through physical and occupational therapy, reviewing and completing the Maintenance of Load Status Test (MOLST) with the patient, consulting with staff, and acknowledging the high complexity of medical decision-making were all parts of the plan. Rehabilitation requirements, pulmonary problems, mental comorbidities, and COVID-19 recovery management were major concerns.
CPT/ICD-10: 99326; U07.1 COVID-19
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