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Care Plan for Mr. Patrick Murphy

Mr. Patrick Murphy is a 70-year-old widower living alone who was recently admitted to the hospital for an infected toe injury that resulted in amputation. He has a history of diabetes, hypertension, and is non-compliant with his medical treatment and lifestyle. His discharge plan includes health education on lifestyle modification, physical therapy to improve mobility, wound dressing, medication, insulin education and diabetic follow up.

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323 views2 pages

Care Plan for Mr. Patrick Murphy

Mr. Patrick Murphy is a 70-year-old widower living alone who was recently admitted to the hospital for an infected toe injury that resulted in amputation. He has a history of diabetes, hypertension, and is non-compliant with his medical treatment and lifestyle. His discharge plan includes health education on lifestyle modification, physical therapy to improve mobility, wound dressing, medication, insulin education and diabetic follow up.

Uploaded by

BINCY
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Case Notes Details
  • Writing Task

CASE NOTES 2

You are Stephy Anne, Charge nurse in the ward where Mr Patrick Murphy is admitted.
Read the case notes below and complete the writing task which follows.

Name : Mr Patrick Murphy


Address : 36 the beaches, Drumgola Wood, Southern Ireland
Phone : +353694721
Age : 70 years
Discharge date : 10/8/19
Social background
 Widower – wife died 2 years back
 Retired postal employee
 Lives alone in own house
 One son – lives abroad with family
 No contact with neighbors – recently shows social isolation
 Smokes 2 packets of cigarette/ day, drinks alcohol 2 bottles/ day
 BMI: 32 ,sedentary life style
 Religion: Roman Catholic, occasional church visit
 Hobbies: watching TV, Addicted to social media
Diet:
 Non compliance with diet
Medical history
 DM- 20 years, on insulin therapy, non compliant
 HTN- since 1990
 Underwent tonsillectomy 10 years back
 Admitted in hospital for prostatectomy in 1998
12/7/19
 Injury to L big toe from a digging fork while gardening
 Profuse bleeding – self treated
19/7/19
 Left big toe infected after injury- consulted general surgeon, refused to suture
the toe
 FBS: 402 mg/dl – referred to diabetologist

29/7/19
 Delayed wound healing
 Pus, swelling, redness, itching but no pain
 Admitted to hospital under diabetologis
 Plan for amputation of the toe
4/8/19
 Surgery done – successful, antibiotics started
 Bp: 160/100 mm of Hg, T : 370 C, R :22 b/m, P : 88 b/m, SPO2 :94%
5/8/19
 Daily dressing done
 Pain –panadol
 Mobility is assisted
 Depressed and more isolated
6/8/19
 No interest in ADL
 Complained lower back pain – needs assistance in walking, showering
 Pain killers administered
10/8/19
 Patient condition satisfactory, needs education on lifestyle modification
Discharge plan
 Health education on life style modification and exercise
 Visit by social worker to help in coping socially
 Physiotherapy to improve mobility
 Daily dressing
 Analgesics and antibiotics to continue
 Education on self administration of insulin
 Follow up in diabetic OPD (17/8/19)

WRITING TASK
 Using the information in the case notes, write a letter to the community health
nurse, Holly Spirit Community Nursing Home, Beaches Road, Cavan, Southern
Ireland, who will be responsible for Mr Murphy’s continued care

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