Multi-System Rehab
Case Study

A female, 86-year-old patient was admitted to Seacrest Rehabilitation and Rehabilitation Center from Hackensack Meridian Southern Ocean Medical Center with an admitting diagnosis of S/P fall at home sustaining several wounds. She has an extensive history of Pacemaker, A-fib, COPD, HTN, TIA, and Osteoporosis.

Reviewed by Dr. James Orlando Cardiologist, Hunter Shahbaz PA, Dr. Robert Mathews Nephrologist, Theresa Esposito PA, Dr. Allen Silvey Pulmonologist, Healing Partner Amy Czenis APN, Therapy team including physiatrist Dr. Chi Mei Wu and the Specialty Program Nurse Coordinator along with the daily clinical care of the nursing team!

Nursing Interventions:

Medication management – diuretic, beta-blocker, anticoagulant, long-acting beta-agonists, vitamins, and supplements.
Wound Care – followed by wound physician, evaluated daily during wound care
Dietary consult – Heart Healthy and electrolyte monitoring
Labs and Diagnostic testing – Frequent labs including UA, In-house bilateral Doppler R/O DVT, and In-house X-ray.

Respiratory Nursing Interventions:

Initial assessment revealed the patient was on 2L of oxygen via N/C which was her baseline. The plan of care consisted of incentive spirometry, coughing & deep breathing exercises, optimize oxygen conservation interventions including medication management.

Therapy:

Upon admission assessment, she required maximum assistance for mobility, and self-care tasks including mobility, toileting, and lower body dressing. She actively participated in therapy to accomplish her goal of returning home. On discharge, she was at a supervision level with self-care tasks, mobility, and transfers. She was able to ambulate 100 ft with a rolling walker.

The patient returned home with the support of her daughter and Bayada Home Care Services. All follow-up appointments were made before her discharge, including Community Primary Care Physician Dr. Caroline Mastro, Dr. Jeffrey Mazzatta, DPM, and Shore Heart Group Cardiologist Dr. James Orlando.

Heart Failure Rehab
Case Study

A male, 93-year-old patient was admitted to Seacrest Rehabilitation and Rehabilitation Center from Atlantic Care Regional Medical Center with an admitting diagnosis of CHF exacerbation. Which resulted in the patient having a pericardiocentesis procedure to remove excess fluid. He has an extensive cardiac history of Heart Failure with an EF of 35%, A-Fib, CAD, Cardiomyopathy, HTN, and Hyperlipidemia.

Reviewed by Dr. James Orlando Cardiologist, Hunter Shahbaz PA, Therapy team including Physiatrist Dr. Chi Mei Wu and the Specialty Program Nurse Coordinator along with the daily clinical care of the nursing team!

Nursing Interventions:

Electrolytic Maintenance including Dietary Consult – Daily weights and Heart Healthy Diet and education.
Medication management – Calcium channel blocker, Anticoagulant, Statin, Antidiabetic medication, supplements, and Insulin Management.
Labs and Diagnostic testing – CBC, CMP, BNP, In-house EKG, X-ray services.

Therapy:

Upon admission assessment, he required maximum assistance with transfers, ambulating, and self-care tasks. He worked diligently with the therapy department to meet his goal of returning home.

On discharge, he was able to perform self-care tasks and transfer at a supervision level and walked up to 100 ft plus with a rolling walker.

The patient returned home with the support of his son and Atlantic Care Home Health. All follow-up appointments were made before his discharge, including APG Cardiologist, Dr. Swarna Jayasighe.

Orthopedic Rehab
Case Study

Male, B.P. 66 years old patient admitted to Seacrest Rehabilitation and Rehabilitation Center from East Orange VA Medical Center with admitting diagnosis of s/p right total knee revision performed by Dr. Joseph Tauro.

The patient is known locally for walking 20 miles per day throughout the Little Egg Harbor community. He graduated from West Pointe in 1979. He became a 2nd Lt. in the United States Army for a total of 14 years. His last rank was Captain serving at Fort Dix. He has an orthopedic history including prior surgical repairs.

Nursing Interventions

Medication management including pain management.
Dietary consultation – including Electrolyte monitoring.
Surgical wound management – Daily wound care and followed wound team weekly.
Labs and Diagnostic testing frequently

Followed by Primary Care Physician Dr. Dhiren Gandhi, the Therapy Team including Physiatrist Dr. Wu, and the Specialty Program Coordinator.

Therapy

Upon admission assessment, the patient required a contact guard for all mobility due to significant deficits in right knee strength and ROM as well as unsupportive standing. The patient’s prior level included multiple miles of outdoor walking daily in the community. Following therapy, the patient was able to achieve independent ambulation on indoor and outdoor surfaces with a straight cane to allow a safe return to home alone.

The patient remained highly motivated to achieve his goals and was extremely happy about the potential to surpass his presurgical gait status.

He returned home with all follow-up appointments and outpatient therapy coordinated with Hackensack Physical Therapy LEH.

Cardiac / Ortho Rehab
Case Study

Female, D.A. 79 years old Patient admitted to Seacrest Rehabilitation and Rehabilitation Center from Atlantic Care Regional Medical Center, Mainland Campus with admitting diagnosis of s/p elective Right Total Knee Replacement performed by Dr. Zachary Post Orthopedic Surgeon of Rothman Orthopedics. The patient has an extensive cardiac history including HTN, New Pacemaker in February 2022.

Nursing Interventions

Medication management including pain management Dietary consult – Heart Healthy Diet and electrolyte monitoring Surgical wound management – Daily wound care and followed wound team weekly Labs and Diagnostic testing frequently

Reviewed by our Post-Acute Care Transitions/Orthopedic physicians Dr. Gabriel Catalina and Dr. Eric Driscoll; Cardiology Dr. James Orlando, and Therapy team including physiatrist Dr. Wu.

Therapy

Upon admission assessment, she required maximum assistance with transfer, ambulation, and self-care task. She worked diligently with the therapy department concentrating on her ability to return home.

On discharge, she was able to perform self-care tasks and transfer independently and walk up to 150 ft with a rolling walker.

After a stay in short-term rehab at Seacrest Rehabilitation, she returned home with Holy Redeemer Home Health Services. All follow-up appointments were made prior to discharge including her community Primary Care Physician Theodore Ende along with Dr. Zachary Post Orthopedic Surgeon.

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