Posted: May 1st, 2025

Lois and Phil: Unfolding Case Study

The home health nurse is planning to visit to Lois Gardener at her home once she is discharged. First, the nurse will get report from the RN case manager at the rehab facility Lois is currently at. Lois was admitted to a rehabilitation bed in a long-term care facility for pulmonary rehab due to COPD and pneumonia.

Please review medical history of Lois. Before discharging Lois, the SBAR report is delivered.

In order to provide patient-centered care, the nurse uses forethought to address possible strengths and indicators of risk in an individual family’s setting. The nurse implements anticipatory planning to promote safety. In your initial post:

• Considering the rehab case manager report and the medical record information, describe three strengths in the Gardner family that the nurse would incorporate into the plan of care. To identify the strengths, consider family structure, setting, and resources.
• List three to four physician-initiated and/or collaborative interventions that the nurse will work with others on to provide effective home care to the family. Consider who and how the nurse will work with other professional and paraprofessional team members. Explain your clinical judgement for choosing these interventions.

NUR109
Module 5
SBAR Report
Person providing report: RN case manager at in-patient rehabilitation unit in a long-term care
facility.
Situation: Lois Gardner is a 75-year-old female we will be seeing weekly for assessment and
medication management. She will be discharged from the rehab facility and returning to
retirement housing with her husband Phil, who is her caregiver. We will be visiting in the
rehabilitation facility to prepare for discharge home.
Background: Mrs. Gardner is a previous smoker and has a history of hypothyroidism, COPD
and CHF.
She recently had a ten-day admission for treatment of COPD and pneumonia. She responded to
antibiotics and respiratory treatments but is now using oxygen about half of the day.
She was sent from the hospital to a rehabilitation bed in a long-term care facility for pulmonary
rehab. She had an MI at age 51 and has previous hospitalizations for pneumonia. She was seen in
the ED two months ago for an episode of angina, treated with nitroglycerin. Her ECG was
normal, and she was sent home following that visit.
Her husband reports that she has become more confused and forgetful over the past year and a
half and requires help with medications and other tasks. This seems to be progressively, slowly
worsening. She was diagnosed with “non-specific dementia,” probably vascular. Her husband
takes care of most of the household duties. The nurses reported that he seemed overwhelmed
with his responsibilities, and with determining the extent of her shortness of breath. She was
unable to describe to him exactly what was going on and how severe it was. He is afraid to leave
her alone.
Her daughter, Sharon, visits several times a week as do several couples from the Gardner’s
synagogue. Sharon lives about an hour away and comes after work. She sometimes brings her
three children with her.
Assessment: Mrs. Gardner is intermittently confused, but cooperative. She becomes disoriented
to place and time at night. She states her name and the names of her family. She is less consistent
with the names of other visitors. She takes medications without difficulty when they are handed
to her. She spends time watching Tv and looking out the window.
Vital signs are stable; she has been afebrile
She requires reminders to eat and drink, but she is independent at mealtime. GI assessment is
normal
NUR109
Module 5
SBAR Report
She has diminished lung sounds and requires reminders to take deep breaths and cough. Her
pulse oximetry levels are stable, but she needs oxygen during meals and activity. She needs
reminders to use her oxygen. She sleeps with several pillows.
Her muscle strength is good, but she is can only walk 15 feet with a walker without becoming
short of breath. She is cooperative with physical therapy sessions.
She is continent and uses the commode.
Recommendation: Since she will be starting on home oxygen, a nebulizer, dietary modifications
and physical therapy, her husband needs support and encouragement. He needs education to
implement the new orders. He has not sought any assistance from family members or outside
agencies.