LTC scenario

Long term care scenario

 

Su is a 78 year old widow who had a severe left MCA stroke.  She was taken to the ER, admitted to acute care and then transferred to an inpatient stroke rehabilitation facility.  She has a supportive family but her daughter  lives in Manitoba with her husband and 3 young children, one son is single and  lives 3 hours away and another son  lives in the same city as Su with his wife and 2 young children.

After 8 weeks in rehab, she is still not able to live on her own, so she is being admitted to a long term care facility next week.

What information should be included in the discharge summary?

What preparation should be done at the long term care facility?

Su made significant progress towards her rehab goals but is still unable to walk independently and ongoing speech and swallowing problems meant that she is on a modified diet.

What should the facility offer Su?

Who should be involved in care planning for Su?

 

 

 

 

Comorbidities include diabetes, knee replacement 5 years ago, atrial fibrillation, hypertension.