If the inter professional team works well together, what health care outcomes might be expected for Edna?

Edna Scott is an 83 YOWF with medical history of uncontrolled hypertension and mild dementia. She lives alone and has limited contact with neighbors. Last month her daughter arranged for her to have visiting nurse services once weekly. Mrs. Scott has been losing weight lately and when a 24 hour recall is collected, it is evident that she is severely under consuming energy and protein and tells the RDN that “ she just doesn’t have much energy to cook these days. “. Edna also states that she is having increasing difficulty making it out to the mailbox to pick up her mail and adds that she “almost slipped in the shower yesterday. “ The nurse also notices that Mrs. Scott has many opened bottles of medication on the counter. The members of the IPT include: home health nurse, home health dietitian and social worker. Can you think of any inter-professional health care professional that you may want to include into the care of this client?

What types of health care conversations might occur between the:

Home Health Nurse & Home Health RDN?

Home Health Nurse & Social Worker?

Social Worker & Home Health RDN?

One day the home health nurse arrives at the residence of Edna Scott and finds her unconscious on the kitchen floor. When an ambulance transports Edna to the ER, the attending physician determines that Edna has had a massive CVA – the consequence s of which include: right sided paralysis and dysphagia. Following her acute care treatment, Mrs. Scott is transferred to a rehabilitation center and is slowly introduced to her inter professional team now composed of : physician, nurse, nurse’s aide, speech therapist, physical therapist, occupational therapist and dietitian.