Care Plan Case study Assessment
- Country :
Australia
| =Name: Preferred name: | DoB: 07:03:59 | Next of Kin: -[ |
|---|---|---|
| Address: Tel: | GP: | Ethnicity: Religion: |
| Medication: Phenytoin Aspirin | Multi – disciplinary Team GP Consultant (clinical neurophysiology for Epilepsy) Consultant (Stroke medicine) Pharmacist Physiotherapist Speech & language Therapist Care Worker | Support Plan – 7 days a week 4 visits a day + taking to appointments. Collecting medication once a month. |
History:
R suffered from a bleed in the brain caused by an intracranial haemorrhage (stroke) and was not found for 48hours. He has been left with needing support with independent living. Prior to this he has had a history of epilepsy. The stroke was on the left side of the brain. He currently lives alone and has done so since having split with his partner 2 years ago. He has one brother who he seldom sees and a few close friends. He did have an active social life prior to his stroke and spent a lot of time at clubs for transvestites as he enjoys dressing in clothes usually associated with women. Prior to leaving the rehabilitation unit he was assessed by an Occupational Therapist and had a range of aids to support him. However, he sees these as being for old people and so does not use them. He is finding it very difficult to adjust to the changes in his life and has been depressed.
| Activity of Daily Living | Need | Plan |
|---|---|---|
| Maintaining a safe environment | Very occasional epileptic seizures (fits). Mostly controlled by medication Unable to collect medication without support Is unsteady when transferring weight from bed or chair. Will not use a lifeline | Monitor and record length of time seizure lasts Call ambulance if over 5 minutes Move anything that may cause harm out of the way Place in recovery position when seizure has finished Collect medication on 1st Thursday of the month Encourage use of equipment Check for possible trip hazards Talk about lifeline where possible. |
| Breathing | No issues identified | N/A |
| Eating and Drinking | Not able to prepare own meals Is Not eating very much as he says he has no appetite | Prepare meals X4 Encourage to eat and drink regularly Offer snacks |
| Eliminating | Occasionally needs help but finds this embarrassing Occasional constipation | Offer to help as required |
| Washing and Dressing | No issues with washing Unsteady in the and Requires help with some aspects of dressing May sometimes wear clothes normally associated with women | Offer to help with dressing when required Accept choice of clothes |
| Controlling Body Temperature | N/A | N/A |
| Mobilisation | Can move around in the flat but is not always steady. Has been supplied with a frame but does not like to use it. Has regular Physio appts Requires a wheelchair outside but does not like to be seen in wheelchair. | Encourage to keep moving Encourage to use frame Support taking to Physio appts when required. Ensure use wheelchair when going out shopping |
| Working and Playing | No longer able to work Has a few friends but does not think ‘they want to see him like this’ Lonely Enjoys listening to music | Spend time talking whilst attending Encourage to see friends either and offer to facilitate outing |
| Communicating | Has some speech difficulties although speech therapy does help Is IT literate and can type | Ask to repeat if not clear Support attendance at Speech therapy Encourage to contact friends virtually |
| Sleeping | No problems | No problems |
| Spiritual needs | Atheist | None identified for support from this service. |
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| Name: James MacDonald Preferred name: Jim | DoB: 24:08:1929 | Next of Kin: Daughter – Jayne Pritchard |
|---|---|---|
| Address: 44, Ridgewood Preanton Tel: 0122 – 234 567 | GP: Dr Singh The Health Centre Preanton Road Preanton Tel: 0122 – 235 888 | Ethnicity: White British Religion: Methodist |
| Medication: Frusemide nifedipine Iron tablets | Multi-disciplinary team GP Pharmacist Home care agency – Care Manager / Care workers Consultant (renal medicine) Consultant (Cardiology) | Support Plan – 7 days a week 8am to 9am 12 to 1pm 6pm to 6.30pm GP visits to be arranged as required |
History:
Jim has been referred to Care at Home for support with his personal care, taking medication, supporting with breakfast and preparing a cooked lunch. He also needs help in the home with laundry. A cleaner comes in once a week. Jim has been in hospital after a fall at home. He has been diagnosed with heart failure and stage 3 renal failure and has high blood pressure which is controlled by medication. His wife died 10 years ago and he has one daughter who lives about 60 miles away. He has lived in his bungalow for about 30 years and is close friends with his neighbour who is of a similar age. He is interested in football. His next door neighbour is also a keen football fan and comes round and watches games with him as well as taking him to football matches occasionally. He had been playing bowls but is now scared of falling so does not always play when he goes. He attends the Methodist Chapel in the village most Sundays. He is still driving although his daughter is concerned about his competence after an incident with another vehicle where he lost his wing mirror. Jim feels that driving is essential to his social contacts.
Activity of Daily Living Need Plan Maintaining a safe environment Jim has had several falls at home. He now has a lifeline alarm he can press when he needs help. He likes to be independent however and tries to do everything for himself. Whilst Care staff should help him get up he is usually up and dressed when the Care staff arrive He requires frusemide twice a day and warfarin once.Collect medication from Pharmacy and re-order repeat prescription Encourage Jim to check his lifeline is working – Sunday am Ensure that there are no rugs or other trip hazards on arrival and when leaving Ensure daily medication is taken Dispense weekly medication into the medidos wallet on Sunday pm. Ensure medication is stored safely Last Friday of each month Breathing Jim has no diagnosed respiratory problems but does get short of breath relating to his kidney failure Encourage Jim to sit down if he is short of breath. Eating and Drinking Since his wife died Jim has relied on frozen ready meals as he has never cooked before. He is reluctant to drink because of the frusemide and incontinence He is teetotal Check Jim has had breakfast Prepare a hot meal for lunch Wash up Check that he has evening meal or food available Encourage Jim to drink fluids with meals Eliminating Jim is sometimes incontinent due to frusemide. He is embarrassed about this and will not wear a pad. He also does not change his clothes when soiled He may suffer from water retention due to kidney failure Encourage Jim to change his clothes if soiled Weigh Jim daily and record weight on weight chart Check for increased swelling of feet and ankles when helping with shoes / slippers and socks Washing and Dressing Jim is usually dressed when care staff arrive but needs support with putting shoes /slippers and socks on Jim is sometimes incontinent due to frusemide. He also does not change his clothes regularly. Jim is usually dressed except for his shoes and socks. Whilst the OT at the hospital felt Jim should have support for a shower or bath he has refused this. He has been provided with a grab rail in the bath (which is a walk in bath) and has a Support with putting on shoes / slippers and socks am Encourage Jim to change clothes when soiled. Support with dressing as required. Offer to help with bath or shower Controlling Body Temperature Jim’s temperature is usually 37 ?C He adjusts central heating and clothing to keep warm or cool down. N/A Mobilisation Jim is a little unsteady on his feet. He has a frame that he sometimes uses otherwise he uses a walking stick. Jim has some arthritis which can affect mobility He is still driving and feels this is important. Encourage mobility and use of stick and frame as required Monitor mobilisation Encourage gentle activity using exercises in the file Working and Playing Jim is usually dressed when care staff arrive but needs support with putting shoes /slippers and socks on Jim is sometimes incontinent due to frusemide. He also does not change his clothes regularly. Jim is usually dressed except for his shoes and socks. Whilst the OT at the hospital felt Jim should have support for a shower or bath he has refused this. He has been provided with a grab rail in the bath (which is a walk in bath) and has a Jim likes to talk about when he was working Encourage Jim to attend the Village Hall Talk to Jim about the cricket / football. Encourage Jim to watch games Communicating Jim is outgoing and enjoys conversations about a range of topics. He is mentally alert and takes an interest in what is happening in the country He is slightly hard of hearing but does not wear a hearing aid Jim reads the paper daily Talk to Jim whilst supporting him Speak in a louder voice if Jim is struggling to hear Collect Jim’s paper from the village newsagent prior to morning call. Sleeping Jim often is tired due to his condition and dozes in his chair. Spiritual needs Jim is a committed Christian and attends chapel regularly Support Jim with celebrating Easter and Christmas Respect the fact that he does not drink alcohol Prepare a fish lunch on Friday if Jim would like this Facilitate contact with the minister where possible
Registered Manager Kathleen O’Malley
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