Care Plan. I want to be communicated to in a way I can understand. I would like to be able to express my needs and wants

Transcription

1 Name: Katie Devaney My preferred name: Kate Care Plan My Birthday is: 16 th January My Room number is: 12 I am allergic to aspirin I am at risk of falls Social History: I grew up in a country town west of Sydney. My father was the local grocery shop owner and on the weekends and afternoons after school I helped in the shop. After I finished school I went on to teachers college and became a primary school teacher. I taught at the local school until I got married. My husband and his family owned a cattle station. After I got married I lived with my husband and his family. I had three girls and two boys. I enjoy cooking and embroidery. I especially enjoyed making birthday cards, with an embroidery picture I made attached the card for my family. Throughout my adult life I was involved in the local volunteer association and organised fund raising activities. I always loved talking with people. My husband passed away when he was 65. The station was inherited by my husband and because I could no longer manage the station we sold it and moved to Sydney. In Sydney I continued to be involved with volunteer organisations until I developed Dementia. I am now at Lotus Compassionate Care because I was finding it difficult to complete my activities of daily living. Communication My comprehension of language isn t as good as it used to be and I sometimes find it difficult to understand what you say Sometimes I feel confused and not able to I want to be communicated to in a way I can understand I would like to be able to express my needs and wants Speak to me in a clear and slow manner Ask me one simple question at a time Be patient while I think about what you have said to I can understand your message If I am confused speak to me in a gentle manner and remind me of where I am. Inspire Education Page 1 of 7

2 express myself makes me feel sad. change in my communication ability, I may require a referral or see my doctor Cultural and Spiritual I sometimes forget I Go to church every Remind me on Sunday morning that I have Church on Sundays and I would Sunday have mass at 10am in the Lotus Compassionate Care Chapel like to maintain my faith Help me choose my Sunday best and spiritual needs. clothes and to be dressed and ready for the support person who will take me to the Chapel. Social and Recreation To maintain recreational and social needs. My memory is not as good as it used to be and I need to keep my mind active. To continue be involved with the things I loved to do. To maintain the current friendships I have. To go on outings with my friends To keep my mind active. Sensory Remind me on Tuesday and Wednesday afternoon that I have Arts and Craft at 2.30pm in the Lotus Compassionate care activity room Remind me on Thursday morning that I have a social outing. Help me choose my clothes and be dressed and ready. Escort me to the activity room or the bus. To maintain visual ability To continue doing the things I enjoy like recreational activities. To continue to see things so I can maintain my independence. Help me to ensure my glasses are clean before I put then on in the morning. vision is getting worse, I may require a referral or see my doctor To continue to see the people I am talking to. Mobility To maintain my mobility. To continue to be Remind me on Monday, Wednesday independent in my and Friday morning that I have To maintain a healthy mobility as long as exercises at 9.30am at the in the Lotus weight. possible. Compassionate care activity room Help me choose my gym clothes and Inspire Education Page 2 of 7

3 Fall risk To keep safe while I am walking to be dressed and ready. Walk beside me to the activity room. mobility is getting worse, I may require a referral or see my doctor Encourage me to use my walking stick correctly Encourage me to walk at a steady pace Encourage me to wear my non-slip good fitting walking shoes Encourage me to wear my glasses Personal Hygiene I sometimes forget to maintain my personal To look nice and feel comfortable hygiene needs To maintain as much independence in selfcare as possible. Remind me in the morning to have a shower and help me choose my clothing. Remind me to ensure the slip mat is on the floor in the shower. Help me to gather and place my toiletries, including my sponge with the long handle in the bathroom. I am able to shower myself but will need assistance with washing my hair. I am able to dry myself but will need assistance with gently pat drying my legs and feet. I will need assistance with applying my make-up and nail polish. The Registered Nurse or Podiatrist will cut my nails. Help me to remember to close the bathroom door so my privacy and dignity can be maintained. Encourage me to do as much as I can for my self-care. Report and document if you notice I become more dependent for self-care, I may require a referral or see my doctor Oral Care I sometimes forget to To maintain healthy I may need to be reminded to put my maintain my oral care gums. dentures in the morning. needs I may need to be reminded to clean my To be able to chew my dentures before bedtime and place Inspire Education Page 3 of 7

4 food and maintain a healthy diet. them in the cup for soaking overnight. gums have signs of irritation, I may require need to see my dentist Skin Care I have sensitive skin To maintain a healthy Remind me to use the sorbolene when skin. I am having a shower and when I wash my hands before having a meal. skin is becoming red and/or the skin is broken, I may require a referral or see my doctor Bladder and Bowel Function I sometimes experience constipation To have a bowel motion every day or every second day I normally open my bowels before I have a shower, report and document in the progress notes if you notice: I have not opened my bowels after three days and/or my faeces is hard to pass and/or my stool consistency is, hard small lumps change in my bladder and/or bowel functions, I may need to see my doctor Sleep I sometimes wake during the night and wander into other residents rooms. To have a restful sleep during the night. To be alert during the day Help me to be active during the day with activities I enjoy Ensure I have a cup of warm milk before bedtime. Help me to be in settled in bed at 9-10pm. Remind me to go to the toilet prior to bedtime if I do not do so change in my sleep patterns, I may need to see my doctor Inspire Education Page 4 of 7

5 Nutrition and Hydration There is a risk of To have good health to obesity. pursue my interests. There is a risk of constipation. Maintain regular bowel motions Remind me when it is meal time. Redirect me if I take other peoples left overs. Encourage me to drink water and/or my choice of low calorie cordial with my meals. Encourage me to have my choice of a cup of tea at morning and afternoon tea. change in my eating patterns, I may need to see my doctor Safety I am sometimes confused with times and place To be safe and decrease the incidents of wandering I am visually impaired I have sensitive skin and I am at risk of sunburn when I am out in the sun. To be safe from trips and falls When I am confused orientate me to time and place by using the effective communication strategies above. If I am anxious gently hold my hand and speak in a gentle voice, this will reassurance me and help me feel safe. Encourage me to wear my glasses. Ensure there are no obstructions where I walk. Encourage me to wear a hat and sunblock when going outside Environment When I am too hot or too cold I feel anxious. To be in an environment with a comfortable temperature When you help me with my personal care ensure the room and water temperature is comfortable. Encourage me to wear appropriate clothing for the weather when I go outdoors. Pain If I am experiencing pain I find it difficult to do activities of daily living When I experience pain I feel anxious. To maintain a manageable pain level so I can optimise my independence To maintain a Report and document if I experience any pain, I may need to be reviewed by my doctor. The Registered Nurse to administer Inspire Education Page 5 of 7

6 manageable pain level so my pain relief medication. I can feel well Behaviour I sometimes get anxious To express my needs and When I am anxious communication have my needs meet with me using the communication strategies above and re-direct me to To feel safe and secure an activity I enjoy. Listen to me when I express a need and assist me to meet that need. Be aware of the triggers that may cause me to feel anxious e.g. pain Help me to maintain my routine. Report and document if I have behaviours of concern, I may require a referral or see my doctor My Medical History: I have dementia, arthritis and CVA My vital signs need to be taken and recorded once a month My weight is to be taken and recorded once a month My medication management needs: I require assistance with my medications. Revision of Support Plan This Care Plan has been discussed with the client and representative: Yes No Consent has been given and recorded: Yes No A copy of this plan is: has been given to the Client/family member/representative. Date of review: has been placed in the clients file. Reason for review: 3 month care review meeting 12 month care review meeting Other * *Provide details for the reason for other Inspire Education Page 6 of 7

7 Client signature: Family member/representative: Claire Devaney Relationship to client: Daughter Registered Nurse: Naja M. Nilsson (RN) Date: 05/11/2012 Additional comments: Inspire Education Page 7 of 7