Community Name: Sans Souci Rehabilitation and Nursing Center
Patient’s Age: 55
Length of Stay:
Reason for Stay: Coronary Atherosclerosis of Unspecified Type of Vessel, Native or Graf, Chronic Airway Obstruction (COPD) Not Elsewhere Classified, Difficulty in walking, Muscle Weakness, Fracture of Fibula Alone; Shaft, Closed.
How did this patient hear about Sans Souci Rehabilitation?
Westchester Medical Center
Details of Experience:
The subject of my case study is Mr. Andrew Ridzik . Mr. Ridzik is a 55 year old white male who was admitted to Sans Souci on 18TH August 2014 at 4:58pm into rm#118. Prior to coming to Sans Souci the patient was at Westchester Medical Center where he had an open heart surgery performed. While being cared for at the hospital patient fell while trying to ambulate alone.
Coronary Atherosclerosis of Unspecified Type of Vessel, Native or Graf, Chronic Airway Obstruction (COPD)Not Elsewhere Classified, Difficulty in walking, Muscle Weakness, Fracture of Fibula Alone; Shaft, Closed.
Upon his admission he was a bit lethargic but we were able to complete the Admission evaluation. He shared that he worked for the company Play land as an engineer. He went on to share that he was married and upon being diagnosed, him and his spouse became separated. After spending about 45mins with the patient on the first day I promised him that I would check in on him the following morning. On my arrival the next morning I went in to say good morning and give a brief visit, he mentioned that he felt a little light headed. This was reported to the Nurse, he was examined and due to an elevated pressure he was sent to the ER on 8/19/14 where he was admitted.
On 8/26/14 he was readmitted to Sans Souci with a Diagnosis of Elevated Blood Pressure w/o Hypertension and occupied room 107P.
Resident was evaluated by Rehab Services on the 26th August 2014. His progress was evaluated in six day increments which started on 8/26/14 – 9/1/14. His short term goals and objective progress was for him:
To perform bed mobility task with Min (A) with the use of side rails for safety awareness to reduce risk for falls.
To perform stand pivot transfers with Mod (A) for safety awareness w/o falls and w/o LOB.
To increase his ability to stand supported for < 30 secs without falls and w/o LOB
At this time he was unable to maneuver himself due to the amount of pain he was experiencing. Mr. Ridzik shared that he was going through a very rough time with his medical issues. He seemed very down and out. He was evaluated by the Psychiatrist who shared that the resident has a Hx of Chronic Depression and was being treated by an outside Source for the last eight years. Psychiatry notes reflects that he has no depression and no signs of anxiety. The Psychiatrist referred Mr. Ridzik to the Psychologist. Resident will be evaluated by the Psychologist on 10/6/12.
His childhood friend Ron visits him each day before lunch. Ron brings lunch in and they eat together. He monitors his friend’s fluid intake. Mr Ridzik is on a fluid restriction due to a Renal deficiency. Besides having a Stroke and a broken Fibula Mr. Ridzik is also on dialysis .He goes to the Dialysis Center for treatment three times a week. It was brought to my attention one day through conversation that his friend served in the Military where he became injured. Ron the resident’s friend shared that while being hospitalized he had a comrade who visited him every day and stayed all day. He said that he made a conscious decision that if he was granted life that he would do the same for a friend.
Resident’s progress was evaluated after his sixth day.
Bed Mobility progress – 8/26/2014: Baseline – Max (A)
9/01/2014: Current – Mod (A)
Stand pivot – 8/26/2014: Baseline – Max (A)
9/01/2014: Current – Mod (A)
Standing support progress – 8/26/2014: Baseline – Max (A)
9/01/2014: Current – Unable
Standing Duration 8/26/2014: Baseline – Unable
9/01/2014: Current –
The therapy department provided Interventions to the Nurses and his caregivers they were instructed in safety precautions and safe transfer techniques in order to increase safety and decrease need for assistance.
Mr. Ridzik was a bit disappointed in his progress report and was a bit down and out for the first few days after receiving the results. He is a middle aged man who is quite aware of his injuries and illness but like most other resident’s at his age are not only dealing with the fact that they are ill but also that they feel confined, bored and sometimes neglected. I coordinated with the Recreation department to set up a care plan for him. He was not interested in attending any of the programs due to the extent of his pain and his dialysis dates. He showed interest in Bingo and 1:1 music therapy. The Director of Recreation picked up on the patient’s interest to attend Bingo. After coordinating with the resident she then contacted the Dialysis center to arrange to have the residents treatment days switched so that he can receive therapeutic recreation activities as a part of his care plan. He started having 1:1 music therapy once or twice a week and his is really enjoying being in the company of the Music Therapist.
On 9/13/14 the resident had a bed transfer from room 107 to 117B which in the beginning he was not happy about, but after meeting with him and explaining some benefits IN having a room- mate may help him during his recovery, he decided to settle in. Resident and I grew a bond and found out that we were both epicurean. In an effort to ensure comfort to the patient I liaised with Dietary to have him have double lunch and dinner portions on the days that he enjoyed the offered meals. He was really happy. After about a week he became settled in to the culture and really started to see light of why he was at Sans Souci and that the staff care about him and his well being.
As of today the patient is doing really well in the community. He is Hydrated, is still at risk for falls, is not constipated, he is not at risk for elopement and his skin condition is intact. In recreation he is now able to attend Bingo programs and Music programs. His rehabilitation progress and respond report as of 9/22/14 reflects:
Standby Assist (SBA) when performing Bed Mobility task.
Contact Guard Assist when performing Functional transfers.
Contact Guard Assist when performing stand pivot transfers.
He has yet to attain maximum improvement and he is compliant with his plan of treatment (POT).
We continue to provide the best treatment and care for Mr. Ridzik, 55 year old male room# 117B so that when he is discharged he can function well again be able to manage his pains, increase Lower Extremity Range of Motion and coordination with dynamic balance.