Proactive Care Team Contingency Plan Original completed: Patient Details. Frameworki Number: First Name: Margaret Lives Alone: Yes No

Transcription

1 Proactive Care Team Contingency Plan Original completed: Patient Details Surname: Jones NHS Number: Frameworki Number: First Name: Margaret Lives Alone: Yes No Known As: Maggie Key safe: Yes No Number available from GP or Proactive care Has CareLine Date of Birth: Allergies: Septrin Contact Number: DNACPR: Yes No Address: 11 Chichester Road Littlehampton Post Code: GP Details GP Name: Dr Smith Surgery: OakTree Surgery Contact Number: Emergency Contact Name: David Jones (lives Bognor) Relationship: son LPA: Yes looking into No Name: Sarah Smith (lives Chester) Relationship: daughter LPA: Yes No Name: Mrs Lloyd (lives Nos. 12) Relationship: Friend & neighbour Care Provider Care Provider Name: Fist Care Contact Number: Care package provided: Three times a day visits, 8.00 (hour), (30mins),19.00 (hour). Assist with dressing, washing, meal preparation, tidy home, providing drinks and snacks, medicines administration. Cleaner via Age Concern 2hrs Wednesday (also does some shopping) Neighbour does shopping weekly Self-Funded or Personal Budget: Direct Payment Council Managed Budget Useful Telephone Numbers Proactive Care Team 9am 5pm Contact Number: x1479 Out of Hours - One Call Contact Number: Page 1 of 5

2 Out of Hours - Adult Services (including people with learning disabilities and older people) Out of Hours - Adult Services Mental Health Act Assessments Worthing East Community Nurses Presenting Conditions Osteoporosis Heart Failure Recurrent UTI CKD stage 3 Contact Number: Contact Number: Contact Number: Option 3 Relevant Observations Pulse: 70bpm (Nov 2014) Respiratory Rate: SP02 on Air: SP02 on 02: BP Range: 138/75 (Nov 2014) BM Range: Temperature: Relevant Medical History & Baseline Mobility: Mrs Jones is well considering her chronic conditions. Osteoporosis causes ongoing pain in back, and mobility is compromised. She walks with zimmer frame in home and 3 wheeler walker outside to car. She can move around bungalow to all rooms and independent with toileting. Mrs Jones is often short of breath but can manage to move around home, but very slowly; her legs are often swollen however has recliner chair and legs raised most of the day. Sleeps in her bed. Mrs Jones has had 3 urinary tract infections over previous 6 months (December May). This is currently under investigation with Urology. Medication Review Date: Completed by: Kayt Blythin - Pharmacist Community pharmacy: Tesco, Littlehampton Medicines management: Medicines are managed form blister packs and collected by care agency monthly. Carers administer medicines. Alendronic acid, Butrans patch are in original packs. Mrs Jones takes her medicines reliably. Smoking history: stopped smoking 40 years ago Alcohol consumption (units/week): none Page 2 of 5

3 Relevant Social History & Current Lifestyle: Mrs Jones lives alone I her own bungalow. Her husband passed away 2 years ago. Her son lives locally and visits 2-3 times weekly. Her daughter lives further away and rarely visits. Mrs Jones is very friendly with her next door neighbour, but otherwise does not know many neighbours. Mrs Jones is housebound now. Her son takes her to appointments if necessary and uses wheelchair from car to hospital. Admission Risks: 1. Worsening Heart Failure 2. Fall 3. UTI Signs to Recognise: 1. Increased swelling of limbs, Increase in weight, Increased shortness of breath, Sensation of bloating, Waking up in the night with sudden shortness of breath, Unable to lay flat, Chest pain, Cough develops/worsens 2. Evidence or report of fall. Patient unable to get off floor/ Difficulty with transfers and mobility, evidence of trauma injuries or bruising 3. Fever; increased confusion; change to frequency, quantity, smell, colour, consistency, suprapubic tenderness. Catheter not draining or bypassing. Page 3 of 5

4 Intervention: (self - care, escalation, urgent) 1. Worsening Heart Failure Self care Weigh daily and record in hand-held record. Ensure maintaining 1.5 Litres fluid restriction/24 hours. Ensure regular medication is taken Monitor limb swelling. Escalation If weight increases by 3-4lbs or more over 2-3days and is accompanied by any of the signs to recognise as identified above-contact Heart Failure Nurse. Heart Failure Nurse to monitor bloods. Inform GP of current situation. Consider contacting one-call to arrange for RAIT to follow-up. Urgent May need to discuss with AMU Consultant if needs admission for IV therapy. 2. Falls Self care Always use zimmer frame to mobilise around home. Take a couple of deep breaths before getting out of chair. Always put leg rest down before getting out of chair. Escalation If patient is not for hospital admission due to their fall, please contact proactive care team so that the patient can be reviewed by a physiotherapist. For wound care needs refer to community nursing team. May need increased package of care for assistance / supervision with mobility to reduce risk of falls. ( Or RAIT for 72hr emergency support) If no bony injury, mobility and pain relief advise. Urgent Call 999 or press CareLine button for paramedic assessment/ admission. Unable to/ willing to move or weight bear. 3. Urinary tract infection Self care: Fluid intake 1.5L/day. To purchase: cranberry products juice or capsules 200mg Escalation: WOMEN: 2 or more signs contact GP/ DNs for possible antibiotics or start standby antibiotics. If no improvement after 3 days dipstick and send urine sample for testing. - Consider need for RAIT Urgent: Sepsis or acute pyelonephritis (dehydration, fever >38 C, heart rate >90/min and respiratory rate >20/min, impaired level of consciousness, profuse sweating, rigors, pallor, significantly reduced mobility): 999 and admit Page 4 of 5

5 Completed by: BN (Case Manager Nurse); KB (Pharmacist); SN (Occ. Thp.) Date completed: Next Scheduled Review Date: (Maximum of 3 months or as required) Distributed to: Patient GP IBIS Frameworki One Call OOH Patient Notes Other (Please State). Patient signature: Page 5 of 5