An Unfortunate

Demonstration of
the Domino Effect of
Decreasing Health

Old Dominion University School of Nursing

Grand Rounds - Rehabilitation Clinical
John Horton
PAST INFLUENCES

Interacting diagnoses: Stage III Chronic Kidney Disease, Atrial

Fibrillation, Coronary Artery Disease, Acute Deep Vein Thrombosis
to Left Lower Extremity, Aortic Aneurysm, Hypercholesterolemia,
Hypertriglyceridemia, Cardiac Arrhythmia.

Past psychosocial, family, and home data: History of depression.

Supportive and healthy wife. Lives in house with wife, daughter,
son-in-law, and two grandchildren. Four steps into house, twelve
steps to second floor bedroom.
PRE-INCIDENT AND CURRENT CAPABILITIES

Pre-Incident: independent, working job.

Current Capabilities: left-sided neglect, mild gross motor impairment, RUE fine motor
intact, LUE fine motor mildly impaired, good sitting balance, fair standing balance, supine
to sit intact, scoot forward and back intact, bed to wheelchair transfers - contact guard
with verbal cues, toilet transfer - minimal assist, tub transfer - minimal assist. ADLs:
setup assist for meals, setup assist for grooming, upper body bathing - supervision, lower
body bathing - minimal assistance, upper extremity dressing - moderate assist, lower
extremity dressing - maximal assist, frequent breaks needed.
CHIEF REASON FOR REHAB

Patient requiring rehabilitation following CVA. Patient is very

capable but continues to display left-sided neglect,
inattention, and distractedness. Primary reason for inpatient
rehabilitation is need to gain strength and endurance in order
to discharge to home to continue occupational, physical, and
speech therapy via home health services.
NURSING INTERVENTIONS AND STRATEGIES

Keep area free of obstacles and hazards, alternatively, direct

attention to potential hazards if they are ignored due to left-sided
neglect.

Speak to patient from his right side.

Potential caregiving issues involve patient’s depression and his wife’s

ability to provide the necessary care. Additionally, the large flight of
stairs will present problems if the patient’s condition continues to
deteriorate.
FIRST WEEK COMPARED TO CONDITION AT
TIME OF DISCHARGE

Unfortunately, this patient experienced decreased functioning in the

days leading up to his discharge. Although he was still able to
ambulate and transfer effectively, his left upper extremity was very
swollen, stiff, and painful at time of discharge. His wife will have to
provide significantly more care and attention as a result of his
condition at discharge as compared to my first week observing this
patient. His condition also appeared to worsen his depression. He
was much more cheerful and communicative during our first three
days together.
DISCHARGE PLANNING

Patient is to be discharged to home with interprofessional home health care services. He

is to be discharged to home as he is able to ambulate, transfer, and perform ADL’s
independently or with his wife’s assistance.

Potential supports include his wife, live-in daughter and son-in-law, and home health
services.

Challenges include management of his worsening condition, potential need for

thoracentesis following discharge, left upper extremity swelling, and management of
blood thinners, as patient had been refusing labs.
DISCHARGE PLANNING CONTINUED

Patient’s greatest fear is the need for painful medical interventions.

Patient supports include his wife and daughter along with home health services

Potential challenges revolve around management of his many comorbidities and depression.

Necessary supports at time of discharge involve training of his wife to be proficient in safe
transferring and the purchasing of a few assistive devices for around their home.

While observing the patient’s wife, it was clear that she had a desire to help and care for her
husband, but it was very apparent that she was nervous about the level of assistance he may
require as a result of his decrease in condition prior to discharge.