Mrs. of the social worker, she has

 

Mrs. Stanley
was at home with her husband eating dinner; suddenly, she noticed weakness in
the left side of her body.  Her husband
called 911, and EMTs soon whisked her away in an ambulance and contacted the
Emergency Room triage nurse while en route, given their suspicion for a stroke.  Upon arrival to the Emergency Room, Mrs.

Stanley was quickly evaluated by Emergency Medicine physicians, Neurologists
and nurses.  Emergency room nurses
obtained her weight (for accurate tPA dosing), quickly established IV access
and drew labs.  She was soon whisked away
to the CT scanner, where a CT technician helped expedite the scan.  A Neuroradiologist quickly provided a
preliminary read of her scans, which confirmed that she was having an ischemic
stroke with no current signs of bleeding. 
The Pharmacist rushed to prepare the tPA for administration by
nursing. 

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Four days
later, Mrs. Stanley is overall doing much better.  It is now time to start discharge discussion.  Her husband recently lost his job and they
have both had a lapse in health insurance. 
With the help of the social worker, she has acquired state funded
Medicaid.  There is, however, a long wait
to place her in a skilled nursing facility (SNF), because the number of beds
funded by Medicaid in the area are sparse. It is estimated that it could take
as long as a month to find placement. 

Which professionals
would be beneficial for collaboration?

The social
worker informs the team that a medication the patient is taking is not covered
by Medicaid. There are certain core measures surrounding medications that must
be met for stroke patients.

What professional would
be beneficial for collaboration with this issue?

The nurse
informs the team that the husband is very upset and is requesting to speak with
the them.  Mr. Stanley worries about his
wife as she is not eating very much, or sleeping well due to having to stay in
a 4-bed room with all the noise. He also feels that the nurses are so busy that
they don’t have enough time for his wife’s needs for bathing and getting her up
to move around. The team finds out that Mr. Stanley has a long history of
alcohol use, but while his wife was at home, he could keep it under
control. 

What professionals
would be beneficial for collaboration?

Is there a professional
role that was utilized prior that would be beneficial again, perhaps for a
different reason?

 

 

 

Conclusion

The physical
therapist and occupational therapist developed a rehab plan and incorporated
Mr. Stanley in the interventions.  After
the speech therapist cleared Mrs. Stanley for oral intake, the dietician was
consulted and recommended supplements to help increase her caloric intake.  The social worker met with Mr. Stanley to
evaluate his coping skills and provided him with information of community
programs to help with his increase in alcohol consumption. The case manager
found a SNF close enough to home that the husband would be able to take public
transportation.  The pharmacist recommended
an alternative medication that was covered by Medicaid and provided discharge
medication counseling on how to take the medication, possible interactions with
other medications and side effects to look out for.  The nurse went over the discharge
instructions (called an after visit summary, or AVS) with the patient and her
husband, clarifying several questions that they had.   

Professionals
involved: PT, OT, SLP, Social Worker, Case Manager, Dietician, RN, and
Pharmacist

 

 

 

 

 

 

 

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