SOCW 6530 wk 6 Assignment 2: Application: Process Recordings

Talked with Mrs. O and her husband this morning here is all the information I have and what recommendations I have. This is for her initial assessment (intake) I asked all these questions and these were the answers. She has MS (muscular sclerosis) and they need more help in the home.

 

1. Offill Female, birthdate xx/xx/xxxx , married phone number xxx-xxx-xxxx

2. Mailing address: PO box xxx Westport Wa. 98595

3. Physical address. They live in a RV 330 S. Forest St. Space xx Westport Wa.

4. Husband and wife are both on SSDI

5. She has Medicare

6. Her Primary doctor: Dr. A

7. Emergency contact her husband: Mr. O cell number: xx-xxx-xxxx

8. Any emails go to husband: [email protected]

9. Allergies: Penicillin

10. Medical condition: MS which she was diagnosed 20 years ago

11. Medications:

· Pregavalin- xxmg x times a day oral

· Baclofen-xxmg x pills during the day and x at night oral

· Modafinil-xxmg x times a day

· Duloxetine-x times a day oral but she could not remember the dosage

· Oxycodone- x/xxx x times a day oral

· Ocrevus- x times a year injection

12. She had her COVID vaccine but no others

13. Height is 5’10 but she has no idea what her weight is says has not been weighed in at least 5 years

14. She handles her medication on her own but is total assist with everything else

15. She is in a wheelchair

16. She has to be lifted in and out of bed she has to have bed baths but the husband says they have someone who is supposed to come in and bath her 2 times a week but they are lucky if they come once a week

17. She is totally incontinent of bowel and bladder

18. Preferred hospital is xxxxxxx

19. She is supposed to wear glasses but doesn’t

20. No hearing aids or hearing issues

21. Does get vertigo

22. No respiratory issues

23. No cardiovascular issues

24. She has trouble swallowing

25. Constipation issues

26. She has a pressure sore that her husband and her say is healing it is on the side of her upper right leg

 

Recommendations

1. Husband asked me to email information I will email and ask if he has copes or DSHS

2. Wife asked about cooling vest I will email them the website that I found for free cooling vest

3. I will recommend she get an appointment with her primary doctor to look at her pressure sore and because we will need updated doctors visits to get them help in the home

4. Even if the bath person is with DSHS or copes we need a new assessment done we recommend he call DSHS and ask for assessment this is the fastest and easiest way