Practice Documenting: Full Case Study

Malik is a 47-year-old with a diagnosis of multiple sclerosis, depression, and anxiety. Malik has a special electric wheelchair so that they can navigate independently in the halls and outside in the courtyard but needs assistance getting in and out of the wheelchair. You are working the 3–11 shift today and are assigned to Malik. Malik has just come back from a doctor’s appointment at 1700. You meet Malik at the door and receive the paperwork from the doctor. You take a set of Malik’s vital signs as per your facility protocol when someone comes back from an appointment. They are as follows: T = 98.8, P = 86, R = 14, BP = 112/72. You write this down in your notebook. You take the paperwork to the nurse and then meet Malik in their room. Once in Malik’s room you note they are red in the face and look upset. You state, “You seem upset, Malik. Would you like to talk about it?” Malik responds with sharing their story about waiting a long time in the clinic waiting room for the appointment and cries while telling the story. No one would talk to Malik and people stared. One person was complaining to another person in the waiting room about their husband being helpless when it comes to household chores and helping with the children. That upset Malik because they wanted to have children, a spouse, and a home to take care of, but since the diagnosis of MS and their quick deterioration they realized they will never have that opportunity. Malik is sad and angry about “missing out on life.” Malik is angry at the person complaining because “at least they have a home and spouse to go home to.” Malik also says the doctor did not offer good news. The disease is progressing quickly, and the doctor fears that Malik may not have use of their hands much longer. That means Malik may not be able to use their wheelchair independently. You sit with Malik while they talk about the experience. You offer support and ask if there is anything you can do. Malik thanks you and then says, “I’m OK, I guess I just needed to get that off my chest—I want to get ready for dinner now.” You then proceed to assist Malik on and off the toilet using a gait belt. Malik is able to use cleansing cloths to freshen up while on the toilet. You change their incontinence pad and conduct a more complete peri-care for them. After cleaning up, Malik heads to the dining room at 1800. Malik sits with their friends. They talk about the basketball game last night. They joke about their own basketball games when they were younger. Tonight Malik has a hearty appetite and can eat without any help from staff. Malik eats most of the chicken sandwich, all the French fries, and about three quarters of the green beans. Malik then goes on to eat both cookies for dessert. Malik drinks the whole carton of milk (240 mL) and a full glass of water (240 mL). Malik then asks for a soda and drinks the full 240 mL can of that too. After dinner Malik’s parents visit. They all sit in the TV room and watch a new reality TV show together. At 2000 you check in on Malik and offer to assist them to the restroom, which they agree to. Malik voids clear, light-yellow urine. The incontinence pad is clean and dry. After washing up, Malik also agrees to the snack. Malik eats half of the banana and three of the four graham crackers that were served. Malik drinks a full carton of milk with that too (240 mL). At 2200 Malik’s parents leave. Malik goes back to their room and plays a game on their phone until about 2215. Normally Malik needs the assistance of one person and a gait belt to transfer from wheelchair to toilet. Tonight Malik states, “I think I am too tired to stand tonight. I would feel safer with the sit-to-stand machine tonight.” You transfer Malik to the toilet using a sit-to-stand machine because their care plan notes that when Malik is tired this is an acceptable substitution for the gait belt transfer. When using the sit-to-stand Malik can grasp the handles and straighten their legs to support the standing movement. When on the toilet Malik has a small bowel movement. It is brown in color, smooth, formed, and soft. There is also urine in the toilet that has pale yellow color. You complete bedtime cares at that time. You remove Malik’s clothes and put on their pajamas with a little help from Malik. Malik is able to place their arms through the pajama top and button several of the buttons on the pajama top. Malik needs more assistance than usual since they are so tired after the long day. Next you place Malik in front of the bathroom sink with the toothbrush and toothpaste, where Malik brushes their teeth independently, though you need to remind Malik to put the toothpaste on the toothbrush before brushing. Malik also combs their hair and returns both the toothbrush and the hairbrush to the drawer in the bathroom. You use the sit-to-stand machine to get Malik into bed and ensure their comfort. Malik can position some of the pillows and move their legs to help you place them under their legs to ensure their heels are not touching the mattress. After you position Malik with pillows to avoid pressure injuries you hand them their phone. You hand Malik the call light and remind them to press it should they need any help moving or using the restroom. Malik watches reels until they decide to stop to fall asleep at about 2300. Malik falls asleep with their phone in their bed as they cannot reach the bedside table. You stop in before the end of your shift to plug the phone in and place it on the bedside table, moving it closer to them. Malik is sleeping soundly at that time.

How would you document the care given to Malik on this 3–11 shift?