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Summary

Assignment 2...

Description

ISBAR Handover Communication I

Identity: Rebecca Smyth, a 44 year old woman who lives in Point Cook with her

husband and young daughter. She has a medical history of Relapsing – Remitting Multiple Sclerosis (RRMS).

S

Situation: She has increasing symptoms of MS such as pain and fatigue, sense

of hopelessness, paraesthesia, muscle spasm, impaired vision, diplopia which affects her balance, and slurred speech.

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Background: lives with husband Jim and 8 years old daughter in a ground

floor apartment. Jim runs his family plumbing business. Rebecca left job as a customer relation officer in Westpac and now helping husband with his accounts. She was diagnosed with Relapsing – Remitting Multiple Sclerosis (RRMS) 3 years ago with symptoms like: • • • • • • •

Spinal syndrome characterised by paraesthesia, pain, muscle spasms and spasticity. Muscle weakness and stiffness in her limbs Increasingly pain and fatigue Sense of hopelessness. Impaired vision Diplopia Slurred speech

Current Medications: • • •

Baclofen TDS. Diazepam nocte. Trial of Gabapentin mane

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Assessment: •

Home/ living environment assessment: lives with husband and 8 years old daughter in ground floor apartment. If she have got any pets? House has overgrown front yard which indicates she may not have been well enough to take care of yard. 3 broken steps in the front door which could have been due to fall this also increases the risk of fall.

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Fall Risk assessment: due to increased symptoms like fatigue, impaired vision, diplopia

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Pain assessment: types of pain, where is the pain, duration of pain and intensity of pain.

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Physical assessment: due to increased pain and increased symptoms need to assess her mobility, ability to perform ADLs with or without assistance, diet, vision, speech and vital observations.

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Psychological assessment: impact of disease on Rebecca and her family. Rebecca experiencing sense of hopelessness.

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Medications assessment: is she compliance or non compliance to medications.

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Carer assessment: it is important to assess their physical and physiological health.

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Social assessment: social support from family and friends. Husbands stay out of home most of the time. Her 8 years daughter needs to be taken care of, not sure if she is able to do that and if she has other family member to give her hand in taking care of her daughter.

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Recommendation: •

Therapeutic pain management: Pharmacological pain relief- Amytriptyline, Gabapentin, Naproxen, Pregabalin. Non pharmacological pain relief: Massage, heat pack, acupuncture, Evening primrose oil (linoleic acid), music therapy, meditation. R/V by pain management specialist (appointment booked 2nd June 23, afternoon). R/v by Physiotherapist for stiffness in limbs and mobility issues ( appointment booked 2nd June, morning)

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Referral to neurologist ( appointment booked on 3rd June, morning )

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Medication r/v, is she is compliant or non compliant to medications

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Referral to dietician- diet can contribute to symptom like fatigue ( appointment booked 10th June, afternoon)

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Referral to speech Pathologist (appointment booked 15th June, afternoon)

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Contact the apartment corporate body and ask to fix 3 broken steps at front door, and mow the front yard.

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Occupational therapist r/v ( appointment booked 5th June 2018, morning)

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Regular health checkup

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Follow up regular eye checkup, Training in visual compensation, environmental modifications, adaptive equipment, as needed.

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Contact with social service to arrange some assistant with ADLs, cleaning, laundries and for caring of 8 years old daughter.

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Education: Provide information to both Rebecca and her family about support available to people and their families in MS. !

In Rebecca’s case the main priority of care is pain management and controlling her increased symptoms. Goal 1: Reduce Rebecca’s pain level (2-4 weeks) •

Assessing her pain level using pain scale 0-10 to determine the duration of pain and when her pain is affection her most.

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Determining her compliance to medication, as that can be contributing in her pain. If she is non compliant determine the effective way to help Rebecca to help her to remember take her medications. Example: setting an alarm in the phone, putting her medication is a spot where she regularly stays in home or a call from community nurse to remind her to take her medication.

Goal 2: Decreased symptoms (2-4 weeks) •

Referral to the neurologist to determine if she is experiencing a new relapses and that they can prescribe medications for symptom control...