Preferred name: DoB: 07:03:59 Next of Kin: -[
=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.
Job Title / Service:
Signature:
Date
Review Date:
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 Jims 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 a retired Local Government Officer
Jim used to play bowls regularly at the Village Hall
He loves sport especially football and cricket. He supports Wolves. 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 Jims 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 OMalley
Signature:
Date
Review Date:
