CASE STUDY

Mental Health Case Study

Mental Health Case Study

E.S. is a 94 year old female, born July 30, 1909. She is widowed. She is of Catholic religion. She stated that her mother was from Germany and her father was from Ireland. She is an only child, and never finished school because she married at a young age. Her date of admission was July 8, 2002 with the diagnosis of left hip fracture and dementia. She was hospitalized for the left hip fracture on July 2, 2002, and then transferred to the nursing facility due to the inability of client to care for herself, as evidenced by inability to remember if she took her medication and needing assistance when toileting. Her code status is a DNR, comfort measures only. Antibiotics for infections are ok, but no feeding tubes or IV fluids. She has full upper and partial lower dentures. She receives a bed bath and has her nails and hair done once a week. She uses a wheelchair for ambulation, she needs assistance to help rise from her wheelchair to stand, and is unable to walk. Activity level is limited to those of which can be done in a wheelchair. She needs stand-by assistance with toileting and helping with transfers to and from her wheelchair.

History of Present Illness

Patient and Chart Information

Chronological Development of Clients Number One Medical Diagnosis

E.S.'s primary medical diagnosis is dementia. Her hip fracture may have been caused by changes in muscle coordination/balance, which is a symptom of dementia (Doenges, Moorhouse, & Geissler, 2002). She now uses a wheelchair for ambulation and needs assistance to transfer to and from her wheelchair. Her hip fracture has now healed, but she is still unable to care for herself due to her decline in cognitive abilities.

Current Signs and Symptoms

Current signs and symptoms of client's primary diagnosis of dementia include forgetfulness, inability to determine whether or not a task had been performed, as evidenced by not being able to remember if she had cleaned her teeth or taken her medications. Inability to recall factual information or recent/past events, as evidenced by inability to orient herself to residence, or if her son had returned from his vacation.

Dementia is a general term for a permanent or progressive organic mental disorder that is characterized by personality changes, confusion, disorientation, deterioration of intellectual functioning, and impaired control of memory, judgment, and impulses. The most common type of dementia is Alzheimer's disease (AD). Increasing evidence supports a role for estrogen in brain regions involved in learning and memory and in the protection and regulation of cholinergic neurons, which degenerate in AD (Fillit, H., September 23, 2002).

Compare and Contrast

Client clearly shows signs of confusion, disorientation, deterioration of intellectual functioning as evidenced by inability to orient to place and time. She has difficulty recalling factual information such as whether or not she has cleaned her teeth that morning or if her meds have been given to her already or not. However, she is able to perform ADL's such as combing her ...