Running Head: LIFE CARE PLAN LIFE CARE PLAN � PAGE \* Arabic \* MERGEFORMAT �8�
Becky Talley
BSN 440, Assignment 3
American Sentinel University
September 27, 2014
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"A Life Care Plan is a dynamic document based upon published standards of practice, comprehensive assessment, data analysis and research, which provides an organized, concise plan reflecting current and future needs with associated costs for individuals who have experienced catastrophic injury or have chronic health care needs" (Weed and Berens, 2010).
Health care planning is a comprehensive assessment of a patient's health concerns where a problems or a list of medical diagnosis generated. Problems can range from medical condition to relationship problems that affect the overall well-being of an individual. Once the problem list or medical diagnosis has been identified goals are developed that are specific to the medical condition, measurable and attainable. In order for each goal to be meet they must be realistic to be measurable.
If a patient suffers from a chronic medical condition that is irreversible the goal would be to help maintain his/her health at the most optimum level as possible.
In the following Life care plan, I have chosen to continue provide a health care plan that extends outside of the emergency room setting. The goal of this plan is to guide all who are to be involved in the care of A.S. so that appropriate treatment can be given.
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Life Care Plan
Prepared For:
A. S.
Certified Disability Examiner: | Rebecca Talley, RN |
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Life Care Plan
Report
Rebecca Talley, RN
SUMMARY PAGE
NAME: | A S |
SOCIAL SECURITY NUMBER: | 123-45-6789 |
DATE OF BIRTH: | 07-28-1950 |
DATE OF ONSET: | 2 weeks |
DATE OF EVALUATION: | 09-20-2014 |
DATE OF COMPLETED REPORT: | 09-26-2014 |
TOTAL TIME (Interview/Record Review, Care Plan Consultations-Research, etc.): | 60 minutes |
DIAGNOSIS: | Axis I: Major Depressive Disorder, Recurrent, Severe Social Anxiety Disorder Rule out generalized anxiety disorder Axis II: R/O Avoidant Personality Disorder Axis III: Migraine Headaches Axis IV: Mild: Having difficulty going to school and considering dropping out Axis V: GAF=55 |
MMI: | N/A |
IMPAIRMENT RATING: | N/A |
PHYSICAL DEMAND LEVEL: | N/A |
Life Care Plan
Report
Referring Party: | None | |
Evaluation Location: | ||
, | ||
Examinee: | A S | |
Date of Onset: | 2 weeks | |
Date of Evaluation: | 09-20-2014 | |
Medical Intake/History Review
Patient suffering from increased depressive mood and anxiety after unable to obtain appointment with current psychiatrist.
MEDICAL RECORDS PROVIDED BY: none provided | |
, |
MEDICAL RECORDS REVIEWED:
R. Talley, RN
Dr. F. A.
CHIEF COMPLAINT AND SUBJECTIVE HISTORY OF PRESENT INJURY BY PATIENT:
"I just feel overwhelmed and can't take it anymore" A.S. is a 22 year old female who reports feeling depressed and difficulties with increased anxiety. Patient states that her symptoms began at the age of 13. She started counseling at the age of 14 but never followed through and became rebellious when forced to go. At age 16 she was started on sertraline 100mg per day and that helped. She began taking Prozac at age 20 but was unable to remember the dosage. Her current anxiety and depression increased almost 2 years ago following the break-up from her boyfried that she hoped to marry one day. She describes her current symptoms as "low mood, decreased interest for most activities, insomnia with an increase in appetite with a 20 pound weight gain over 9 months. Her increased feelings of worthlessness and decreased energy have left her feeling anxious. Concentration is decreased, and she feels like her mind is constantly racing with thoughts of her failed relationship. These symptoms have made it very difficult for her to function and concentrate in school and she has considered dropping out of school. She reports feelings of "wanting to die" and admits to having had active suicidal ideations in the past. Currently she denies having a plan. She does state that had suicidal ideations at the age of 15 but never acted on them. Patient is currently being followed by a psychiatrist Dr. R.M. and is currently taking venlafaxine 75 mg daily for her anxiety and depression. Patient has only been on the venlafaxine after her long time dose of Prozac had become ineffective. Patient was tried on a 6 week trail of escitalopram 10 mg but was discontinued after one week after experiencing side effects of worsening migraine headaches. Patient states that she feels herself becoming more despondent and is upset that in a week will be the anniversary of her first date of her ex-boyfriend. Patient denies hallucinations, grandiose ideations, flight of ideas or current suicidal or homicidal ideations.
EFFECTS OF INJURY ON DAILY LIVING:
This 22 year old female has a long history of social anxiety that has impacted her life negatively in the areas of education, socially and occupationally. Prozac was an effective medication to treat her depression until the loss of a relationship and grief triggered her depression and anxiety to spiral out of control. This lead the patient to seek the help of a psychiatrist. Patient does not make eye contact with provider throughout the interview. Patient may meet the criteria for avoidant personality disorder due to severe social anxiety. Most concern is placed on her major depressive episode that has currently lasted 2 years at the time of this interview.
CURRENT PHYSICAL COMPLAINTS:
Patient states that she has had an increase in migraine headaches for the past two weeks. She also complains of generalized aches and pains as her anxiety increases.
PAST MEDICAL HISTORY:
Surgical History: | None |
Past illnesses/injuries: | None |
Prior on-the-job injuries: | None |
Allergies: | NKDA |
FAMILY AND SOCIAL HISTORY:
The patient was born in Fairfax, Virginia, the youngest of 3 children with 2 older brothers. Her father is retired Navy and her mother stayed at home while she was growing up until she went back to school to become a nurse. She describes her relationship with her parents as close. She states she is closer with her mother but is embarrassed to discuss her feelings with her parents since "they wouldn't understand." Patient admits that she is uncomfortable around people in social situations, and would rather stay home. She currently lives at home with her parents. Patient states her childhood was okay and that they moved around a lot due to her father being in the military. She never felt like she could ever have any close friends because either she moved or her friends moved. She first reports her symptoms of anxiety started in middle school "out of place" in her new school. She felt paralyzed with anxiety when she was called on in class. Eventually at age 16 she dropped out of school so she wouldn't have to interact with other kids which only increased her anxiety. Staying home all day without a job only increase her depression and irritability. At that point her mother scheduled her an appointment with a psychiatrist and was started on sertraline 100mg qd. This allowed her symptoms of depression and anxiety manageable for her to obtain her G.E.D. and get a clerical job at a local insurance company. She quit her job two years ago and has been a fulltime student studying accounting. Patient has a decreased interest in previous hobbies she once enjoyed (reading, surfing the internet, and spending time gardening and taking care of her pets (2 cats and 1 dog)). As far as support patient states she has one girlfriend that she rarely sees. She has one friend at school that she sometimes goes out with, but she hasn't been seeing her lately. She admits and increase consumption of prescription pills daily and binge drinking.
CURRENT MEDICAL AND REHABILITATION SITUATION:
Current physician: Dr. R. McDonald for psychiatric medications: Venlafaxine 75mg po qd
FINANCIAL SUMMARY:
Patient states that she is currently on her parent's medical insurance. She also states that she is able to afford the co-payment to obtain her medications.
Conclusions
Treatment Plan: Patient is currently not suicidal and does not meet the criteria for hospitalization. Outpatient treatment is recommended.
1.ER physician has recommend that Venlafaxine to be increased to 150mg qd for 7 days, On day 8 increase Venlafaxine 225mg qd for 7 days, and on day 15 increase Venlafaxine to 300mg qd. Increasing the noradrenergic reuptake properties of venlafaxine it will allow the medication to be more effective. Side effects of Venlafaxine include insomnia, increase in blood pressure and insomnia (Medline Plus).
2. Physician has also prescribed Rozerem 8 mg PO qd for patient's insomnia. This medication non-habit forming and is a melatonin receptor agonist (Medline Plus).
3. Referral of patient to a counselor to begin cognitive behavioral therapy to assist with the grieving over her ended relationship, and to assist her with anxiety so that she might be better able to achieving coping skills. List provided to patient with names and phone numbers.
4. Recommend that patient follow up with her psychiatrist within ASAP for medical management and changes made by ED physician. Appointment Scheduled for Monday, September 29, 2014 at 10:00 AM
5. Encourage community resources for support groups and phone numbers if patient feels worse or becomes suicidal. Encourage patient to return to the ED to reevaluate her situation or be considered for hospitalization. National Suicide Hotline: 1-800-273-8255. Emergency Dispatch: 911. Online Support: http://www.suicidefindinghope.com/content/online_support_groups
Thank you for allowing me to evaluate your client. Please contact me at your earliest convenience should you wish to have further discussion regarding my conclusions and subsequent Life Care Plan.
Sincerely yours,
Rebecca Talley
RN
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Appendix A
Life Care Plan
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Life Care Plan
Appendix A-2: Future Medical Care - Surgical Intervention or Aggressive Treatment Plan | |||||||
Recommendation (Description) | Purpose | Frequency of Procedure | Per Procedure Cost | Cost Per Year | Non-Recurring Cost | Growth Trend | Recommended By |
Psychiatrist | Management of psychiatric medications | 1 x per month | 150.00 | 900.00 | To be determined by an economist | ED physician |
Cost Per Year (subtotal) = $900.00
Life Care Plan
Appendix A-3: Drug Needs | ||||||
Drugs (Prescriptions) | Purpose | Per Unit Cost | Cost Per Year | Non-Recurring Cost | Growth Trend | Recommended By: |
3Venlafaxine | antidepressant | 9.98 | 3512.96 | TBD | ER Physician | |
rozerem | insomnia | 9.37 | 3298.24 | TBD | ER Physician |
Cost Per Year (subtotal) = $6,811.20
Life Care Plan
Appendix A-7: Projected Therapeutic Modalities | |||||||
Therapy | Age / Year Initiated | Purpose | Frequency of Treatment | Base Cost per Year | Non-Recurring Cost | Growth Trend | Recommended By: |
counseling | Cognitive behavioral therapy | bi-monthly | 2600.00 | To be determined by an economist | ED physician |
Base Cost per Year (subtotal) = $2,600.00
Life Care Plan Financial Summary
Description | Cost Per Year | Non-Recurring Cost |
Appendix A-1: Future Medical Care-Routine | $0.00 | $0.00 |
Appendix A-2: Future Medical Care - Surgical Intervention or Aggressive Treatment Plan | $900.00 | $0.00 |
Appendix A-3: Drug Needs | $6,811.20 | $0.00 |
Appendix A-4: Supplies | $0.00 | $0.00 |
Appendix A-5: Diagnostic Testing / Educational Assessment | $0.00 | $0.00 |
Appendix A-6: Projected Evaluations | $0.00 | $0.00 |
Appendix A-7: Projected Therapeutic Modalities | $2,600.00 | $0.00 |
Appendix A-8: Aids for Independent Function | $0.00 | $0.00 |
Appendix A-9: Orthotics / Prosthetics | $0.00 | $0.00 |
Appendix A-10: Wheelchair Needs | $0.00 | $0.00 |
Appendix A-11: Wheelchair Accessories | $0.00 | $0.00 |
Appendix A-12: Orthopedic Equipment | $0.00 | $0.00 |
Appendix A-13: Home Care / Institutional Care | $0.00 | $0.00 |
Appendix A-14: Transportation | $0.00 | $0.00 |
Appendix A-15: Home Furnishings and Accessories | $0.00 | $0.00 |
Appendix A-16: Architectural Renovations / Housing Options | $0.00 | $0.00 |
Appendix A-17: Leisure Time and / or Recreational Equipment | $0.00 | $0.00 |
Appendix A-18: Potential Complications | $0.00 | $0.00 |
TOTAL: | $10,311.20 | $0.00 |
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Resources
Beck Institute for Cognitive Behavioral Therapy. (http://www.beckinstitute.org).
Medline Plus: http://www.nlm.nih.gov/medlineplus/druginfo/meds
Ornstein, R. (1988). Psychology: The study of human experience (2nd Ed.). Orlando, FL: Harcourt Brace Jovanovich, Publishers
Weed RO, Berens DE. 2010. Private Sector Rehabilitation. In: JH Stone, M Blouin, editors. International Encyclopedia of
Rehabilitation. Available online:
http://cirrie.buffalo.edu/encyclopedia/article.php?id=11&language=en
Plan model is based on role and function research of life care
planners conducted at Southern Illinois University and meets
the certification criteria established by the
Commission on Disability Examiner Certification