Your case management review will provide a detailed evaluation of the provision and coordination of care for one older client  (80 years plus who has, cognitive impairment mixed Alzheimer’s, 2nd Fall to Parkinsons, AF, HT, CCF, T2DM, Dyslipidemia, etc) with whom you have worked during your clinical placement.

Your review should address the following points:

1.      Introduction of your client.

Ensure both the person and the organisation have been de-identified.

2.      Outcomes of a comprehensive health assessment

You need to assess your client using an appropriate framework. Please use the provided Nursing Assessment Framework to collect data (this is not included in the word count): conduct an interview, perform physical examinations and review relevant documentation. The Nursing Assessment Framework may be completed electronically or by hand. If handwritten, please ensure it is legible.

Handwritten documents will need to be scanned for electronic submission with the Case Management Review.

The completed Nursing Assessment Framework must be attached to your Case Management Review submission.

3.      Pathological changes (symptom presentation and impact on your client)

Select the main condition that represents a priority for this client (e.g. related to current admission to acute care, reason for admission to residential facility). You need to discuss the impact of pathological changes on the older person and their functioning.

4.      Nursing care needs:

1. a.      Medication

Discuss your client with regard to their medication and the nursing care involved in administration.

Consider issues (as relevant) such as:

• over the counter (OTC) medications,
• polypharmacy,
• time of administration
• route of administration
• requirements to ‘crush’

Support your discussion with relevant literature.

b.     Coordination and management of your client’s care

1. i.       Mental health issues
2. ii.       Skin care: identifying patients/residents at risk and prevention of pressure injuries
3. iii.       Nutrition
4. iv.      Incontinence
5. v.      Prevention of functional decline
6. vi.      Confusion/delirium
7. vii.       Falls
8. viii.       Sleep and rest
9. ix.      Pain

Select two (2) of the above areas that are relevant to your client and review (evaluate) the coordination and management of their care under the following headings:

a)     Assessment

Review areas such as:

• Risk/assessment scales provided by the facility
• Frequency of assessment
• Risk rating as identified by assessment tool

b)     Actions/preventive measures

Discuss care actually delivered and documented.

c)     Actual outcomes

Evaluate care outcomes for your client.

d)     Analysis of evidence