Care Plan
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- Words: 6,561
- Pages: 29
1 Ann Sample Dr Green
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:27 for Andrew Mark Jones
Surname:
Jones
Placement:
23 Alfred Street Filton Bristol BS34 7TP
Other Names:
Andrew Mark
Title:
Mr
Preferred Name:
Andrew
Contact No.:
(01275) 397 500
Date of Birth:
16/06/1937
Occupation:
Bus Driver
Marital Status:
Widowed
Religion:
Christian (C of E)
Maiden Name:
Reason for Admission:
Nationality:
British
Eye Colour:
Green
Hair Colour:
Grey
Height:
1.55
Weight:
58kg (9st 2lb)
Build:
Medium
Hair Length:
Short
Eye Wear:
None
Hearing Aid:
BTE
Facial Hair:
None
Admission Date:
01/01/2008
Discharge Date:
Long Term Care
From:
Previous Home
To:
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:27 for Andrew Mark Jones
Relationship: Business Telephone:
GP 01234 567 890
Address:
Local Health Centre 99 North Road Town Name Postcode
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Photograph Date Of Birth:
16/06/1937
Room Number:
1
Keyworker:
Ann Sample
Date Updated:
20/06/2008
Written By:
Ann Sample
Date of Review: Time of Review: Location of Review: Next Review Date:
December 2008
Name:
Andrew Mark Jones
Signature: Name:
Ann Sample
Relationship:
Key Worker
Signature: Name: Relationship: Signature: Name: Relationship: Signature: Name: Relationship: Signature: Name: Relationship: Signature:
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin
Care Summary Andrew continues to settle well at Demonstration Home, he has made new friends with staff and residents alike. Andrew needs some guidance with his intake of food to promote his health. Andrews care file will be updated on a continuing basis to reflect any changes in his care needs. Medical History To be entered manually... Previous Placement To be entered manually... Updated on 09/09/2008 by Admin
Statement of Purpose: Andrew is aware of how to access the home's statement of purpose and residents' guide. Information contained within these documents will allow him to take advantage of all the facilities the home has to offer. Complaints Procedure Andrew is unsure of the homes complaints procedure. He should be reminded as appropriate about the homes complaints procedure and given a written copy for his reference if he does not presently have one. Care File Andrew is not aware that he has a right to access all information stored in his Care File. Andrew should be reminded as appropriate that should he wish to access this information he only needs to ask a member of staff.
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin
Dementia Andrew's last dementia assessment was conducted on 17 July 2008, when it was concluded that Andrew suffers from acute forms of Lewy Bodies dementia. Sometimes Andrew's dementia can cause confusion and hinder communication between himself and others, carers should remain patient and calm with him when communicating as it can be distressing to him. Andrew's dementia occasionally makes him appear to wander without purpose, carers should try to assist him when necessary to maintain his safety. Andrew sometimes suffers from short term memory loss which can affect his day to day needs and Andrew occasionally loses his long term memory resulting in him forgetting things from the past. Andrew may repeat himself due to memory loss. Carers should remember to be understanding and patient to his needs. Symptoms Due to Andrew's dementia he sometimes expresses frustration vocally which may cause him to raise his voice without apparent reason. If Andrew expresses vocal frustration by raising his voice he may need to be reassured that everything is ok. If possible, carers should try to create a calm environment by reducing background noise and try to remain calm themselves at all times. Dementia occasionally makes it difficult for Andrew to recognise family and friends that visit him. This may cause confusion and distress for both him and his relatives. If Andrew has difficulties with recognising family and friends that visit he may need reassurance, and it may be necessary to reassure the friend or family member as it could be distressing to both parties. Emotional needs Sometimes Andrew can suffer increased temper or rapid mood swings which could be due to frustration from his dementia. Carers should try to remain calm as this will make him calmer and reduce his temper. Andrew can occasionally appear frustrated and lack personal contentment within himself, most probably due to his dementia. Degree of risk:
Very High Risk
Risk ● Andrew is at risk as he suffers from acute forms of lewy bodies dementia. ● There is some risk of Andrew becoming vocally frustrated causing distress to him and others. ● There is some risk that Andrew may become frustrated if he is unable to recognise family and friends that visit. ● Andrew may suffer from increased temper or rapid mood changes, putting him and others at risk. ● Andrew occasionally feels frustrated, putting him at risk. ● There is some risk that communication with Andrew will become difficult due to his dementia. ● Andrew may be at risk of forgetting his day to day tasks as he has some short term memory loss. ● Andrew's sense of wellbeing is at risk as he suffers from some long term memory loss. Dementia continued on page: 4...
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Prevention ● If Andrew has raised his voice it may be necessary to try and create a calm and friendly atmosphere by reducing background noise and remaining calm. ● Andrew should be given emotional support if he is unable to recognise family and friends that visit. ● Carers should remain calm and patient if Andrew suffers from increased temper or rapid mood changes. ● Andrew should be given emotional support if he seems occasionally frustrated. ● Carers should remain calm and patient when Andrew is trying to communicate. Assistance Required
(Assistance from 2 carers) Updated on 17/07/2008 by Admin (RCPD)
Abuse Andrew was assessed on 17 July 2008 when it was concluded that Andrew shows no signs or symptoms of physical, emotional, financial, sexual abuse or neglect. Degree of risk:
Low Risk
Risk ● Currently Andrew is at very low risk as he does not show any signs or symptoms of abuse. Prevention ● Even though Andrew does not currently show any signs or symptoms of abuse, he should continue to be monitored so that his safety and wellbeing is maintained. Assistance Required
(Completely independant)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin
General Health Andrew's last general health assessment was conducted on 17 July 2008. Andrew does not suffer from stomach ulcers but occasional stomach pains can cause Andrew discomfort, affecting his wellbeing. Andrew has never experienced any dizziness and he has not suffered any blackouts. Andrew suffers from occasional headaches which will put his wellbeing at risk, however he does not experience any migraines. Andrew does not experience any chest pain. Andrew can sometimes experience nausea, this may be unsettling to him. It is known that Andrew does not currently smoke and he has not smoked in the past. Andrew suffers from type two diabetes. Andrew requires diet only diabetic control. Andrew's glucose level should be checked at least once a day. Andrew may require some assistance in controlling his diabetes, it is important to assist him so that any risks are minimised. Strokes It is known that Andrew has not suffered from any strokes in the past. Tissue viability Malnourishment and age are intrinsic factors which could affect Andrew's skin viability. Also pressure and friction are extrinsic factors which could affect Andrew's skin viability. Andrew uses a foam cushion to relieve pressure. Degree of risk:
Moderate Risk
Risk ● Headaches are a risk to Andrew's general wellbeing. ● Andrew is at risk as he occasionally suffers from stomach pains. ● Andrew is currently at low risk as he has not suffered any strokes in the past. ● Andrew is at low risk of smoking related health issues as he has never been known to smoke in the past. ● Andrew may be at some risk as he suffers from type two diabetes. ● Andrew may be at some risk if not given assistance to control his diabetes. ● Andrew may be at risk as he may have skin conditions or problems. Prevention ● Headaches could be prevented by medication but other forms of prevention may also be needed. ● Andrew's diet should be reviewed if he suffers from stomach pains not caused by other medical problems. ● Andrew should continue to be monitored to make sure he has not suffered any strokes. ● Andrew should be given help and encouragement to choose food and drink that will promote his diabetic health. Assistance Required
(Completely independant)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin
Ability Andrew's last mobility assessment was conducted on 31 July 2008. Andrew's overall level of mobility was found to be an area where particular attention needs to be paid to ensure Andrew remains risk free when moving and has the appropriate support and guidance when necessary. When moving around the home Andrew has a confident approach to his mobility. Andrew can sometimes become breathless when walking. It is therefore important to consider exertion with regard to movement. A balance between good exercise and over exertion should be achieved. Andrew moves using slightly short, low and uneven paces. Stiff joints cause Andrew to often find movement difficult. Assistance Required Andrew's overall level of mobility is moderate, however only occasional guidance is needed. Andrew will ask for assistance or guidance when and as needed. Andrew finds difficulty in covering large distances and therefore where possible journey distances should be minimised and alternative arrangements made when this is not possible. Andrew needs support and guidance to take steady even paced steps with good ground clearance to minimise risks. Andrew sometimes forgets his aid and needs reminding of its correct use Aids Used Andrew is able to balance independently whilst moving using a walking frame. Andrew is able to move over short distances (below 50 meters) without assistance using his walking frame for stability. Andrew sometimes forgets his walking frame, however is able to use it independently with occasional guidance. Degree of risk:
Moderate Risk
Risk ● Andrew sometimes becomes breathless and is at minor risk of health related consequences. ● Andrew's independence is at risk from limited mobility. ● Andrew's paces are short and uneven increasing the risk of tripping. ● Andrew has low ground clearance whilst moving about which increases the risk of tripping. ● Andrew exercises infrequently, and his mobility is at risk of deteriorating. ● Andrew sometimes forgets his walking aid and is at risk of becoming unsteady without it. ● Andrew sometimes forgets how to use his aid correctly. Prevention ● Andrew should rest at appropriate intervals; any health concerns should be investigated with his GP. ● Andrew should be encouraged to remain mobile, this will help him in remaining independent. ● Andrew should be given support and guidance to promote safe mobility with regards to paces. ● Andrew should be positively encouraged to become more active and to increase exercise to aid better mobility. ● Andrew should be frequently reminded to remember his aid when moving about. ● Andrew should be given occasional support and guidance in the correct use of his aid. Assistance Required
(Guidance from 1 carer)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 17/07/2008 by Admin (RCPD)
Ability Andrew's last assessment in outside mobility was conducted on 17 July 2008, when it was concluded that his overall level of mobility outside was good. Andrew suffers from occasional travel sickness which may cause him some discomfort when traveling long distances. Andrew is able to access the external environment safely when unaccompanied. Degree of risk:
Low Risk
Risk ● Andrew is at very low risk as his level of mobility is good. ● There is a risk of Andrew suffering from occasional travel sickness. Prevention ● Andrew may require travel sickness medication when traveling to prevent him feeling unwell and suffering from discomfort. ● Even though Andrew's mobility when outside is good he should continue to be monitored so that any change in this situation can be noted. Assistance Required
(Completely independant) Updated on 17/07/2008 by Admin (RCPD)
Transfers Currently Andrew is able to transfer independently without the use of any aid. Degree of risk:
Low Risk
Risk ● Andrew is at low risk as he is able to transfer independently without the use of any aid. Prevention ● Andrew is currently able to transfer independently, however this situation should continue to be monitored for any change. Assistance Required
(Completely independant)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 17/07/2008 by Admin (RCPD)
Ability At present Andrew is able to dress and undress independently. Andrew has no known clothing related allergies. Choice Andrew is currently able to make independent choices regarding his clothing, it is important for him to remain in control of the selection of his clothing as much as possible to maintain his individuality. Degree of risk:
Low Risk
Risk ● Andrew is at low risk as he is able to dress and undress himself independently. ● Currently Andrew is at low risk as he does not have any known clothing related allergies. Prevention ● Andrew is currently able to dress and undress independently, however he should continue to be monitored in case this situation changes. ● Andrew has no known allergies to any types of clothing, he should be monitored to ensure this does not change in the future. Assistance Required
(Completely independant) Updated on 09/09/2008 by Admin
General Andrew requires some assistance to maintain his personal hygiene. This is important to promote Andrew's wellbeing and reduce the risk of becoming ill or suffering from infections. Andrew requires no encouragement to maintain his personal hygiene at levels that will maintain his wellbeing but he requires frequent reminding or prompting. It is important for Andrew to wash more frequently as this will promote his general cleanliness and improve his sense of wellbeing. Carers should assist him to maintain a level of cleanliness that is beneficial to him and to maintain an acceptable level of hygiene, this could be achieved by encouragement to wash more frequently. Andrew requires some assistance when shaving. Andrew may be at some risk of suffocation in water if left unsupervised. It may be necessary to assist Andrew when washing to minimise the risk of suffocation. Daily Wash Andrew may require assistance when turning taps on and off. Andrew requires some assistance in using a washing aid when washing. These aids include items that help reach places like his back etc. Andrew requires assistance when washing his face, torso and other areas of his upper body, however he requires little assistance to wash his lower body area and legs. Degree of risk:
Moderate Risk
Personal Care continued on page: 9...
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Risk ● Andrew may be at risk of injury if maintaining personal hygiene without some assistance. ● Andrew may be at risk of not washing himself at appropriate intervals if not given frequent prompting. ● Andrew's hygiene is at risk if he does not wash at frequent enough intervals. ● Andrew may be at risk of injury if not assisted when shaving. ● Andrew requires some assistance when manipulating taps, which may put him at risk of injury if not assisted. ● Andrew may require some assistance and aids when washing he is at risk of injury without these. ● Andrew may be at some risk of suffocation if left in water unsupervised. Prevention ● It is recommended that Andrew receives some assistance to maintain his level of personal hygiene. ● If neccesary Andrew should be reminded to wash at appropriate intervals. ● Andrew should be encouraged to wash more frequently to prevent poor hygiene. ● Andrew should be given assistance when shaving to prevent injury. ● Andrew should be given some assistance when using taps. ● Andrew should be given bathing aids to help him wash himself. ● Andrew should be given some assistance when washing his upper body, face and torso. ● Andrew should be given some assistance when washing his lower body and legs. ● Andrew should be given supervision when washing to reduce the risk of suffocation in water. Assistance Required
(Guidance from 1 carer) Updated on 11/09/2008 by Admin (RCPD)
Bathing Andrew is able to make his way to the bathroom with some assistance. It is important for Carers to ensure that he is given assistance at appropriate intervals to promote his comfort and wellbeing. Carers should make Andrew aware that they are available to assist him to the bathroom whenever required. Andrew is able to independently choose his preferred method of bathing. When bathing Andrew feels he has sufficient privacy and his dignity is being upheld and respected, This is important for Andrew to maintain his self esteem. Andrew's religious or spiritual beliefs do not affect his bathing requirements. Andrew's preferred method of bathing is a shower. When bathing Andrew uses no bathing aid to promote his safety. Degree of risk:
Low Risk
Risk ● Andrew may be at some risk of injury if left unattended when making his way to the bathroom. Prevention ● Andrew should be given assistance as required for him to make his way to the bathroom and maintain his personal hygiene and promote wellbeing. Assistance Required
(Completely independant)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin
General Some assistance is needed for Andrew to choose appropriate quantities of food and liquids. Carers should encourage Andrew to choose appropriately for his diet. Andrew is able to use food utensils without any assistance but he may require some assistance to cut his food into appropriate sized pieces for his consumption. Carers should try to make sure that his food is proportioned sufficiently, reducing any risk. Andrew does not require any specially adapted utensils to consume food or liquids. Diet Without assistance Andrew may not maintain a healthy balanced diet. Carers should encourage him to maintain a healthy diet. Andrew requires occasional encouragement to amend his diet to promote weight control. Carers can assist by encouraging him to amend his diet accordingly. Andrew has religious beliefs but they do not effect his diet. Degree of risk:
Moderate Risk
Risk ● Andrew may be at some risk if he does not have sufficient assistance when selecting appropriate quantities of foods and liquids. ● Andrew may be at some risk if he does not have sufficient assistance to cut his food into appropriate sized pieces for his consumption. ● Andrew may be at some risk as he might have some difficulties with swallowing food. ● Andrew is at risk of not maintaining a healthy balanced diet without assistance. ● Andrew is at risk as he does not maintain a healthy balanced diet. ● Andrew is at risk of losing or gaining weight if not given occasional encouragement regarding his diet. Prevention ● Some assistance could be given to Andrew when he is selecting appropriate quantities of food and liquids. ● Andrew may require his food to be cut into appropriate sized pieces for his consumption. ● Frequent encouragement should be given to Andrew to assist him in maintaining a healthy balanced diet. ● Andrew could be given occasional encouragement to amend his diet to promote weight control. Assistance Required
(Total support)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 17/07/2008 by Admin (RCPD)
Urinary Continence Andrew's last urinary continence assessment was conducted on 17 July 2008. At present Andrew is fully urinary continent and does not require any assistance, however this should be reviewed on a regular basis to ensure his needs are met and wellbeing is promoted. Bowel Continence Andrew's last bowel continence assessment was conducted on 17 July 2008. At present Andrew is fully bowel continent and does not require any assistance, however this should be reviewed on a regular basis to ensure his needs are met and wellbeing is promoted. Andrew can occasionally experience diarrhoea, he may require some emotional and physical support in this matter as it may affect Andrew's feelings and sense of wellbeing. Abilities Andrew may require assistance when transferring on and off the toilet, carers should use an appropriate aid to minimise risks. Andrew requires occasional physical assistance when gaining access to the toilet. Andrew may require some support with his personal hygiene after using the toilet, carers should assist him with this matter if and when necessary. Andrew requires very infrequent reminding or prompting to use toilet facilities. Degree of risk:
Low Risk
Risk ● There is some risk of injury if Andrew is not given some assistance when transfering on and off the toilet. ● Andrew is at some risk if he does not have some assistance when accessing the toilet. ● Andrew's personal hygiene may be at risk without some assistance after using the toilet. Prevention ● Carers should give Andrew some physical support when transferring on and off the toilet. ● Andrew may need to be given some additional assistance to access the toilet. ● Andrew should be given some occasional assistance with his personal hygiene after using the toilet. ● Carers should give Andrew infrequent prompting to use toilet facilities. Assistance Required
(Guidance from 1 carer)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin (RCPD)
Night Checks Andrew can sometimes venture outside his room at night times, this could put him at risk of injury due to low lighting. Occasional nightmares can be experienced by Andrew, affecting his wellbeing. Carers should try to reassure him and give emotional support when possible. Restlessness at night times can occasionally be experienced by Andrew, this can affect his wellbeing and also make him feel tired during the day. Andrew may be at some risk of injury during the night. Carers should try to ensure that he has a safe environment. This may include providing good lighting. Bed Rails Andrew does not require bed rails fitted to his bed when resting. Degree of risk:
Moderate Risk
Risk ● Andrew may be at risk as he sometimes ventures outside his room at night. ● Andrew's wellbeing may be at risk as he suffers from occasional nightmares. ● Andrew is occasionally restless at night, this may put his sense of wellbeing at risk and he may feel tired during the day. ● Andrew is at some risk of injury during the night. Prevention ● Andrew should be assisted if he sometimes ventures outside his room during the night. ● Andrew should be reassured and emotionally supported if he experiences occasional nightmares. ● Carers should try to create a safe environment for Andrew at night. Assistance Required
(Guidance from 1 carer) Updated on 17/07/2008 by Admin (RCPD)
Environment Control Andrew requires some assistance to control his own environment such as turning lights on and off, or adjusting heating. Carers should assist him when necessary. Andrew requires some assistance with opening and closing windows, as he finds it difficult to use the mechanism. Carers should ensure that he has assistance when opening and closing his windows. Andrew requires occasional assistance when opening, closing, locking and unlocking doors. Carers should ensure that these are checked before he retires to bed and after he wakes up. Degree of risk:
Moderate Risk
Environmental Control continued on page: 13...
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Risk ● Andrew may be at risk if he has difficulties controlling his environment. ● Andrew may be at risk if not given some assistance when opening and closing windows. ● There may be some risk to Andrew if he does not receive some assistance when opening, closing, locking and unlocking doors. Prevention ● Andrew should be given some assistance when controlling his own environment in regards to heating and lighting. ● Andrew should be given some assistance to open and close windows. ● When opening, closing, locking and unlocking doors Andrew should be given some assistance. Assistance Required
(Guidance from 1 carer) Updated on 09/09/2008 by Admin
Verbal Communication Andrew uses speech to communicate with others. Senses Andrew's vision in his left eye is moderate, however the vision in his right eye is good. Andrew's overall vision is moderate, this may put him at risk of injury if he cannot see hazards which may cause an obstruction. Carers should ensure that if he wears a vision aid that he uses it as necessary and they should also give any other assistance that will promote his safety and wellbeing. Andrew uses prescription glasses to increase his visionary perception. Andrew's overall level of hearing is moderate. This may make communication difficult and pose potential risks. When speaking to Andrew it is especially important to speak in a clear and loud voice. It is important to do this with respect and not in a potentially patronising manner. It may also prove useful to reduce background noise and move closer so Andrew can hear clearly. Andrew may be unable to hear alarms or someone trying to identify a danger, it is important to identify this factor when conducting risk assessments. Andrew's level of hearing in his left ear is good but the level of hearing in his right ear is moderate. Andrew uses a hearing aid to increase his audio perception. When last assessed Andrew's overall level of perception via touch was found to be very good. Cognition Currently Andrew is able to fully understand what is spoken to him.
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 17/07/2008 by Admin (RCPD)
Administration Some assistance or prompting may be necessary for Andrew to remember to take his medication, it is important for carers to remind him to take his medication when prescribed. Andrew does not suffer any known pharmaceutical allergies. A medication risk assessment has been completed for Andrew. Degree of risk:
Moderate Risk
Risk ● Andrew may be at some risk if he is not reminded occasionally to take his medication. Prevention ● Andrew occasionally needs to be reminded to take his medication. ● A medication risk assessment should be kept up to date and current for Andrew's safety. Assistance Required
(Guidance from 1 carer) Updated on 17/07/2008 by Admin (RCPD)
Oral Health Currently Andrew is able to maintain his teeth and oral hygiene independently. Updated on 17/07/2008 by Admin (RCPD)
Social Andrew is currently able to have a full understanding of who is visiting when family and friends visit him. Andrew does not require any assistance when socialising with friends, family and visitors. Emotional Andrew does not currently show any signs or symptoms of emotional health problems. Degree of risk:
Low Risk
Risk ● Andrew is at low risk as he fully understands who is visiting when family and friends come to visit. ● Andrew is at low risk as he does not require any assistance when friends and family visit. ● Andrew is at low risk as he does not show any signs or symptoms of emotional health problems. Emotional Needs continued on page: 15...
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Prevention ● Andrew should continue to be monitored in case he requires assistance when socialising with family and friends in the future. ● Even though currently Andrew shows no signs of emotional health problems he should continue to be monitored in case this situation changes. Assistance Required
(Completely independant) Updated on 17/07/2008 by Admin (RCPD)
Religious Needs Andrew is Christian. Language Andrew's native language is English Updated on 17/07/2008 by Admin (RCPD)
Outings Currently no factors impact upon Andrew's safe enjoyment of external outings or events. General Interests Andrew sometimes requires assistance to participate in entertainment activities inside the home, carers should assist him when necessary as this would improve his safety. Andrew can occasionally lose interest in entertainment activities more quickly than most, this may be due to the type of activity or other reasons, carers should try to identify these reasons and act accordingly to improve Andrew's enjoyment. Updated on 26/08/2008 by Admin
Overview To be entered manually...
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 17/07/2008 by Admin (RCPD)
Preferences Andrew's last wishes were discussed on 17 July 2008, when it was concluded that he was willing to discuss and record his last wishes. Should Andrew experience a life threatening condition he wishes not to have medical aid to assist recovery. In the event of him experiencing a terminal condition he wishes to reside at the current residence. If his health deteriorates beyond the homes capacity to provide effective care he wishes to transfer to a more effective care environment. He does not have any funeral arrangements in place. Andrew already has last will arrangements in place. He wishes his next of kin to be contacted in such circumstances. He does not wish for his body to be donated to health or scientific facilities. Andrew is willing to review his last wishes again in the future. Updated on 14/05/2008 by Admin
Demo Residential Home, based on the needs assessed within this care plan, confirms the individuals needs can be encompassed safely and effectively within our home environment and the care we provide. Should the individuals needs change this care plan will be reviewed to ensure the individuals well-being is maintained. Managers Signature/Date:________________________________________
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
The purpose of this document is to ensure Andrew’s needs are always accurately reflected within this care plan. Although a full review/re-assessment is conducted at least every 6 months; this process ensures that any minor alterations are recorded so information held in this file is as current as possible and to ensure a review is prompted should any major needs require immediate reassessment. This review process is also a legal requirement in compliance with CSCI standard 7.4.
Last Care Plan Full Review: Next Full Review Due:
20 June 2008 December 2008
No amendments required at current time (Current copy in place) Minor amendments required (Amendment made to computer/paper copy) Major amendments necessary (Full review required) Name:________________________Signature:______________________ Date:__________
No amendments required at current time (Current copy in place) Minor amendments required (Amendment made to computer/paper copy) Major amendments necessary (Full review required) Name:________________________Signature:______________________ Date:__________
No amendments required at current time (Current copy in place) Minor amendments required (Amendment made to computer/paper copy) Major amendments necessary (Full review required) Name:________________________Signature:______________________ Date:__________
No amendments required at current time (Current copy in place) Minor amendments required (Amendment made to computer/paper copy) Major amendments necessary (Full review required) Name:________________________Signature:______________________ Date:__________
No amendments required at current time (Current copy in place) Minor amendments required (Amendment made to computer/paper copy) Major amendments necessary (Full review required) Name:________________________Signature:______________________ Date:__________ Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Instructions: Start Date: Notes: Further information:
ONE to be taken EVERY DAY 01/01/2008 Stop Date: Aspirin is used to relieve mild to moderate pain; reduce fever, redness, and swelling; and to help prevent blood from clotting. It is used to relieve discomfort caused by numerous medical problems, including headache, infections, and arthritis. It is also used to reduce the risk of a second heart attack or stroke. Larger doses of aspirin are used to treat gout.
Instructions:
ONE to be taken TWICE A DAY
Start Date: Notes: Further information:
09/06/2008
Instructions: Start Date: Notes: Further information:
Instructions: Start Date: Notes: Further information:
Instructions: Start Date: Notes: Further information:
Stop Date:
Atenolol is used alone or in combination with other medications to treat high blood pressure. It also is used to prevent angina (chest pain) and treat heart attacks. Atenolol is in a class of medications called beta blockers. It works by slowing the heart rate and relaxing the blood vessels so the heart does not have to pump as hard.
ONE to be taken AT NIGHT 09/06/2008 Stop Date: Corticosteroids are inhaled to help prevent asthma attacks and to ease breathing problems. They work by reducing swelling and irritation in the small air passages of the lungs.
ONE to be taken EVERY DAY 11/06/2008 Stop Date: Bisoprolol is used alone or in combination with other medications to treat high blood pressure. Bisoprolol is in a class of medications called beta blockers. It works by slowing the heart rate and relaxing the blood vessels so the heart does not have to pump as hard.
ONE to be taken TWICE A DAY 01/01/2008 Stop Date: Calcium supplements are taken by individuals who are unable to get enough calcium in their regular diet or who have a need for more calcium. They are used to prevent or treat several conditions that may cause hypocalcemia (not enough calcium in the blood). The body needs calcium to make strong bones. Calcium is also needed for the heart, muscles, and nervous system to work properly.
75 Kg
71 Kg
67 Kg
63 Kg
59 Kg
* Average 55 Kg
51 Kg
47 Kg
43 Kg
39 Kg 1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
19
1 2 3
02/01/2008 08/01/2008 15/01/2008
57 Kg (8st 14lb) 56 Kg (8st 11lb) 56 Kg (8st 11lb)
20 21
4 5 6 7 8
22/01/2008 29/01/2008 05/02/2008 12/02/2008 19/02/2008
56.5 Kg (8st 13lb) 56.8 Kg (8st 13lb) 57 Kg (8st 14lb) 57.9 Kg (9st 2lb) 58.1 Kg (9st 2lb)
22 23 24 25 26
9 10 11
26/02/2008 04/03/2008 11/03/2008
58 Kg (9st 2lb) 57.2 Kg (9st 0lb) 56.1 Kg (8st 12lb)
27 28 29
12 13 14 15 16
18/03/2008 25/03/2008 01/04/2008 08/04/2008 15/04/2008
55.9 Kg (8st 11lb) 56 Kg (8st 11lb) 56.2 Kg (8st 12lb) 56.5 Kg (8st 13lb) 56.4 Kg (8st 12lb)
30 31 32 33 34
17 18
22/04/2008 29/04/2008
56.8 Kg (8st 13lb) 57.1 Kg (8st 14lb)
35 36
03/06/2008
58 Kg (9st 2lb)
Relationship: Home Telephone:
Friend 0151 6287384
Address:
Union Street Hoylake Wirral CH47 7TU
Mobile Telephone:
07870 573 885
Relationship: Home Telephone:
Friend 01275 583 493
Address:
123 Station Road Portishead Bristol BS20 3ER
Relationship:
GP
Address:
Business Telephone:
01234 567 890
Local Health Centre 99 North Road Town Name Postcode
Relationship: Home Telephone: Mobile Telephone:
Son 01792 665 423 07870 486 939
Address:
3 Danygraig Road Swansea Wales SA2 3NT
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Cod and chips Roast dinner Mashed potato
Curry Sweed Cheesecake
Chess Cards Bowls Group outings
Watching Tv
Get up early and have tea
Going to bed late
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Weight:
58 kg
Height:
1.55 meters
1.90m
1.85m
1.80m
1.75m
1.70m
1.65m
1.60m
1.55m
1.50m
1.45m 40kg
50kg
60kg
70kg
80kg
90kg
100kg 110kg 120kg 130kg 140kg
BMI under 20; under weight BMI 20 to 25; ideal weight BMI 25 to 30; over weight BMI 30 to 40; obese BMI 40 and over; very obese Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
5/10
General - (Residents rights and data protection)
2/10 7/10 9/10 7/10 7/10
General - (Dementia overview) Symptoms - (Symptoms of dementia) Emotional - (Emotional needs relating to dementia) Confusion - (Confusion) Memory loss - (Memory loss)
10/10 N/A N/A N/A 10/10 N/A
General - (Signs of abuse) Physical - (Signs of physical abuse) Emotional - (Signs of emotional abuse) Financial - (Signs of financial abuse) Neglect - (Signs of neglect) Sexual - (Signs of sexual abuse)
8/10 8/10 10/10 10/10 10/10 7/10
General - (Overview of health) Tissue Viability - (General tissue health) Strokes - (Health Related to Strokes) Respiratory - (Health related to respiratory) Heart - (Health related to heart) Diabetic - (Diabetic need)
8/10 7/10 7/10 9/10 10/10 6/10
General - (Overview of mobility) Physical Ability - (Physical abilities with regard to mobility) Mobility Aid Use - (Aid used to mobilise) Assistance Required - (Assistance and guidance required) Falls / Risks - (Indentify areas of risk regarding mobility) Orientation - (Orientation, Attitude)
9/10
General - (Overview of mobility outside)
10/10
General - (Overview of transfers)
10/10 10/10 N/A 10/10
General - (General dressing ability) Choice - (Clothing choice) Clothing Items - (Clothing items) Risk - (Dressing risk)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
7/10 6/10 10/10
General - (Personal care overview) Daily Wash - (Daily washing needs) Risk - (Risk of injuries)
9/10
General - (General bathing)
7/10 7/10 10/10
General - (General appetite) Diet - (Diet) Risks - (Risks at mealtimes)
10/10 9/10 7/10
Urine - (Urine continence) Bowel - (Bowel continence) Abilities - (Abilities)
7/10 10/10
General - (Night check risks) Bed Rails - (Use of bed rails)
8/10
General - (Environmental control)
10/10 7/10 10/10 7/10 10/10
Communication - (General communication) Eyesight - (Eyesight) Touch - (Sense of touch) Hearing - (Hearing) Cognition - (General cognition)
9/10 10/10
General - (Medication overview) Risks - (Medication risks)
10/10
General - (Oral health overview)
10/10 10/10
General - (General emotional needs) Emotional - (Emotional related health)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
10/10
General - (General religion and languages)
10/10 9/10
Outings - (External events, performances, theatre) General Interests - (Visual and audio entertainment)
10/10
General - (General palliative care arrangements)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
1
2
3
4
5
6
7
8
9
10
11
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02 July 2008 - Dentist - Shirehampton Dentists Andrew had a checkup at the local dentists. Dentist said everything was fine and booked an appointment in six months time.
02 July 2008 - Hairdresser - home Andrew had his hair washed and cut by the visiting hairdresser.
05 July 2008 - Dinner Outing Andrew had a dinner outing with his son Stephen Jones. Andrew had a good time and enjoyed the meal.
07 July 2008 - Telephone Call - home Andrew received a telephone call from his Friend Jason Cooper.
11 July 2008 - Telephone Call - home Andrew received a telephone call from his son Stephen Jones.
16 July 2008 @ 10:45 - Doctor Visit Dr Green visited to check up on Andrew. Dr Green recommended that he should have some blood tests taken.
23 July 2008 @ 13:30 - Blood Test - BRI Andrew was taken to the BRI to have some blood tests taken. Andrew will receive the results in a few weeks.
25 July 2008 - Reminder Andrew requested to be reminded to call his friend Jason Cooper today.
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:27 for Andrew Mark Jones
Surname:
Jones
Placement:
23 Alfred Street Filton Bristol BS34 7TP
Other Names:
Andrew Mark
Title:
Mr
Preferred Name:
Andrew
Contact No.:
(01275) 397 500
Date of Birth:
16/06/1937
Occupation:
Bus Driver
Marital Status:
Widowed
Religion:
Christian (C of E)
Maiden Name:
Reason for Admission:
Nationality:
British
Eye Colour:
Green
Hair Colour:
Grey
Height:
1.55
Weight:
58kg (9st 2lb)
Build:
Medium
Hair Length:
Short
Eye Wear:
None
Hearing Aid:
BTE
Facial Hair:
None
Admission Date:
01/01/2008
Discharge Date:
Long Term Care
From:
Previous Home
To:
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:27 for Andrew Mark Jones
Relationship: Business Telephone:
GP 01234 567 890
Address:
Local Health Centre 99 North Road Town Name Postcode
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Photograph Date Of Birth:
16/06/1937
Room Number:
1
Keyworker:
Ann Sample
Date Updated:
20/06/2008
Written By:
Ann Sample
Date of Review: Time of Review: Location of Review: Next Review Date:
December 2008
Name:
Andrew Mark Jones
Signature: Name:
Ann Sample
Relationship:
Key Worker
Signature: Name: Relationship: Signature: Name: Relationship: Signature: Name: Relationship: Signature: Name: Relationship: Signature:
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin
Care Summary Andrew continues to settle well at Demonstration Home, he has made new friends with staff and residents alike. Andrew needs some guidance with his intake of food to promote his health. Andrews care file will be updated on a continuing basis to reflect any changes in his care needs. Medical History To be entered manually... Previous Placement To be entered manually... Updated on 09/09/2008 by Admin
Statement of Purpose: Andrew is aware of how to access the home's statement of purpose and residents' guide. Information contained within these documents will allow him to take advantage of all the facilities the home has to offer. Complaints Procedure Andrew is unsure of the homes complaints procedure. He should be reminded as appropriate about the homes complaints procedure and given a written copy for his reference if he does not presently have one. Care File Andrew is not aware that he has a right to access all information stored in his Care File. Andrew should be reminded as appropriate that should he wish to access this information he only needs to ask a member of staff.
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin
Dementia Andrew's last dementia assessment was conducted on 17 July 2008, when it was concluded that Andrew suffers from acute forms of Lewy Bodies dementia. Sometimes Andrew's dementia can cause confusion and hinder communication between himself and others, carers should remain patient and calm with him when communicating as it can be distressing to him. Andrew's dementia occasionally makes him appear to wander without purpose, carers should try to assist him when necessary to maintain his safety. Andrew sometimes suffers from short term memory loss which can affect his day to day needs and Andrew occasionally loses his long term memory resulting in him forgetting things from the past. Andrew may repeat himself due to memory loss. Carers should remember to be understanding and patient to his needs. Symptoms Due to Andrew's dementia he sometimes expresses frustration vocally which may cause him to raise his voice without apparent reason. If Andrew expresses vocal frustration by raising his voice he may need to be reassured that everything is ok. If possible, carers should try to create a calm environment by reducing background noise and try to remain calm themselves at all times. Dementia occasionally makes it difficult for Andrew to recognise family and friends that visit him. This may cause confusion and distress for both him and his relatives. If Andrew has difficulties with recognising family and friends that visit he may need reassurance, and it may be necessary to reassure the friend or family member as it could be distressing to both parties. Emotional needs Sometimes Andrew can suffer increased temper or rapid mood swings which could be due to frustration from his dementia. Carers should try to remain calm as this will make him calmer and reduce his temper. Andrew can occasionally appear frustrated and lack personal contentment within himself, most probably due to his dementia. Degree of risk:
Very High Risk
Risk ● Andrew is at risk as he suffers from acute forms of lewy bodies dementia. ● There is some risk of Andrew becoming vocally frustrated causing distress to him and others. ● There is some risk that Andrew may become frustrated if he is unable to recognise family and friends that visit. ● Andrew may suffer from increased temper or rapid mood changes, putting him and others at risk. ● Andrew occasionally feels frustrated, putting him at risk. ● There is some risk that communication with Andrew will become difficult due to his dementia. ● Andrew may be at risk of forgetting his day to day tasks as he has some short term memory loss. ● Andrew's sense of wellbeing is at risk as he suffers from some long term memory loss. Dementia continued on page: 4...
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Prevention ● If Andrew has raised his voice it may be necessary to try and create a calm and friendly atmosphere by reducing background noise and remaining calm. ● Andrew should be given emotional support if he is unable to recognise family and friends that visit. ● Carers should remain calm and patient if Andrew suffers from increased temper or rapid mood changes. ● Andrew should be given emotional support if he seems occasionally frustrated. ● Carers should remain calm and patient when Andrew is trying to communicate. Assistance Required
(Assistance from 2 carers) Updated on 17/07/2008 by Admin (RCPD)
Abuse Andrew was assessed on 17 July 2008 when it was concluded that Andrew shows no signs or symptoms of physical, emotional, financial, sexual abuse or neglect. Degree of risk:
Low Risk
Risk ● Currently Andrew is at very low risk as he does not show any signs or symptoms of abuse. Prevention ● Even though Andrew does not currently show any signs or symptoms of abuse, he should continue to be monitored so that his safety and wellbeing is maintained. Assistance Required
(Completely independant)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin
General Health Andrew's last general health assessment was conducted on 17 July 2008. Andrew does not suffer from stomach ulcers but occasional stomach pains can cause Andrew discomfort, affecting his wellbeing. Andrew has never experienced any dizziness and he has not suffered any blackouts. Andrew suffers from occasional headaches which will put his wellbeing at risk, however he does not experience any migraines. Andrew does not experience any chest pain. Andrew can sometimes experience nausea, this may be unsettling to him. It is known that Andrew does not currently smoke and he has not smoked in the past. Andrew suffers from type two diabetes. Andrew requires diet only diabetic control. Andrew's glucose level should be checked at least once a day. Andrew may require some assistance in controlling his diabetes, it is important to assist him so that any risks are minimised. Strokes It is known that Andrew has not suffered from any strokes in the past. Tissue viability Malnourishment and age are intrinsic factors which could affect Andrew's skin viability. Also pressure and friction are extrinsic factors which could affect Andrew's skin viability. Andrew uses a foam cushion to relieve pressure. Degree of risk:
Moderate Risk
Risk ● Headaches are a risk to Andrew's general wellbeing. ● Andrew is at risk as he occasionally suffers from stomach pains. ● Andrew is currently at low risk as he has not suffered any strokes in the past. ● Andrew is at low risk of smoking related health issues as he has never been known to smoke in the past. ● Andrew may be at some risk as he suffers from type two diabetes. ● Andrew may be at some risk if not given assistance to control his diabetes. ● Andrew may be at risk as he may have skin conditions or problems. Prevention ● Headaches could be prevented by medication but other forms of prevention may also be needed. ● Andrew's diet should be reviewed if he suffers from stomach pains not caused by other medical problems. ● Andrew should continue to be monitored to make sure he has not suffered any strokes. ● Andrew should be given help and encouragement to choose food and drink that will promote his diabetic health. Assistance Required
(Completely independant)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin
Ability Andrew's last mobility assessment was conducted on 31 July 2008. Andrew's overall level of mobility was found to be an area where particular attention needs to be paid to ensure Andrew remains risk free when moving and has the appropriate support and guidance when necessary. When moving around the home Andrew has a confident approach to his mobility. Andrew can sometimes become breathless when walking. It is therefore important to consider exertion with regard to movement. A balance between good exercise and over exertion should be achieved. Andrew moves using slightly short, low and uneven paces. Stiff joints cause Andrew to often find movement difficult. Assistance Required Andrew's overall level of mobility is moderate, however only occasional guidance is needed. Andrew will ask for assistance or guidance when and as needed. Andrew finds difficulty in covering large distances and therefore where possible journey distances should be minimised and alternative arrangements made when this is not possible. Andrew needs support and guidance to take steady even paced steps with good ground clearance to minimise risks. Andrew sometimes forgets his aid and needs reminding of its correct use Aids Used Andrew is able to balance independently whilst moving using a walking frame. Andrew is able to move over short distances (below 50 meters) without assistance using his walking frame for stability. Andrew sometimes forgets his walking frame, however is able to use it independently with occasional guidance. Degree of risk:
Moderate Risk
Risk ● Andrew sometimes becomes breathless and is at minor risk of health related consequences. ● Andrew's independence is at risk from limited mobility. ● Andrew's paces are short and uneven increasing the risk of tripping. ● Andrew has low ground clearance whilst moving about which increases the risk of tripping. ● Andrew exercises infrequently, and his mobility is at risk of deteriorating. ● Andrew sometimes forgets his walking aid and is at risk of becoming unsteady without it. ● Andrew sometimes forgets how to use his aid correctly. Prevention ● Andrew should rest at appropriate intervals; any health concerns should be investigated with his GP. ● Andrew should be encouraged to remain mobile, this will help him in remaining independent. ● Andrew should be given support and guidance to promote safe mobility with regards to paces. ● Andrew should be positively encouraged to become more active and to increase exercise to aid better mobility. ● Andrew should be frequently reminded to remember his aid when moving about. ● Andrew should be given occasional support and guidance in the correct use of his aid. Assistance Required
(Guidance from 1 carer)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 17/07/2008 by Admin (RCPD)
Ability Andrew's last assessment in outside mobility was conducted on 17 July 2008, when it was concluded that his overall level of mobility outside was good. Andrew suffers from occasional travel sickness which may cause him some discomfort when traveling long distances. Andrew is able to access the external environment safely when unaccompanied. Degree of risk:
Low Risk
Risk ● Andrew is at very low risk as his level of mobility is good. ● There is a risk of Andrew suffering from occasional travel sickness. Prevention ● Andrew may require travel sickness medication when traveling to prevent him feeling unwell and suffering from discomfort. ● Even though Andrew's mobility when outside is good he should continue to be monitored so that any change in this situation can be noted. Assistance Required
(Completely independant) Updated on 17/07/2008 by Admin (RCPD)
Transfers Currently Andrew is able to transfer independently without the use of any aid. Degree of risk:
Low Risk
Risk ● Andrew is at low risk as he is able to transfer independently without the use of any aid. Prevention ● Andrew is currently able to transfer independently, however this situation should continue to be monitored for any change. Assistance Required
(Completely independant)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 17/07/2008 by Admin (RCPD)
Ability At present Andrew is able to dress and undress independently. Andrew has no known clothing related allergies. Choice Andrew is currently able to make independent choices regarding his clothing, it is important for him to remain in control of the selection of his clothing as much as possible to maintain his individuality. Degree of risk:
Low Risk
Risk ● Andrew is at low risk as he is able to dress and undress himself independently. ● Currently Andrew is at low risk as he does not have any known clothing related allergies. Prevention ● Andrew is currently able to dress and undress independently, however he should continue to be monitored in case this situation changes. ● Andrew has no known allergies to any types of clothing, he should be monitored to ensure this does not change in the future. Assistance Required
(Completely independant) Updated on 09/09/2008 by Admin
General Andrew requires some assistance to maintain his personal hygiene. This is important to promote Andrew's wellbeing and reduce the risk of becoming ill or suffering from infections. Andrew requires no encouragement to maintain his personal hygiene at levels that will maintain his wellbeing but he requires frequent reminding or prompting. It is important for Andrew to wash more frequently as this will promote his general cleanliness and improve his sense of wellbeing. Carers should assist him to maintain a level of cleanliness that is beneficial to him and to maintain an acceptable level of hygiene, this could be achieved by encouragement to wash more frequently. Andrew requires some assistance when shaving. Andrew may be at some risk of suffocation in water if left unsupervised. It may be necessary to assist Andrew when washing to minimise the risk of suffocation. Daily Wash Andrew may require assistance when turning taps on and off. Andrew requires some assistance in using a washing aid when washing. These aids include items that help reach places like his back etc. Andrew requires assistance when washing his face, torso and other areas of his upper body, however he requires little assistance to wash his lower body area and legs. Degree of risk:
Moderate Risk
Personal Care continued on page: 9...
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Risk ● Andrew may be at risk of injury if maintaining personal hygiene without some assistance. ● Andrew may be at risk of not washing himself at appropriate intervals if not given frequent prompting. ● Andrew's hygiene is at risk if he does not wash at frequent enough intervals. ● Andrew may be at risk of injury if not assisted when shaving. ● Andrew requires some assistance when manipulating taps, which may put him at risk of injury if not assisted. ● Andrew may require some assistance and aids when washing he is at risk of injury without these. ● Andrew may be at some risk of suffocation if left in water unsupervised. Prevention ● It is recommended that Andrew receives some assistance to maintain his level of personal hygiene. ● If neccesary Andrew should be reminded to wash at appropriate intervals. ● Andrew should be encouraged to wash more frequently to prevent poor hygiene. ● Andrew should be given assistance when shaving to prevent injury. ● Andrew should be given some assistance when using taps. ● Andrew should be given bathing aids to help him wash himself. ● Andrew should be given some assistance when washing his upper body, face and torso. ● Andrew should be given some assistance when washing his lower body and legs. ● Andrew should be given supervision when washing to reduce the risk of suffocation in water. Assistance Required
(Guidance from 1 carer) Updated on 11/09/2008 by Admin (RCPD)
Bathing Andrew is able to make his way to the bathroom with some assistance. It is important for Carers to ensure that he is given assistance at appropriate intervals to promote his comfort and wellbeing. Carers should make Andrew aware that they are available to assist him to the bathroom whenever required. Andrew is able to independently choose his preferred method of bathing. When bathing Andrew feels he has sufficient privacy and his dignity is being upheld and respected, This is important for Andrew to maintain his self esteem. Andrew's religious or spiritual beliefs do not affect his bathing requirements. Andrew's preferred method of bathing is a shower. When bathing Andrew uses no bathing aid to promote his safety. Degree of risk:
Low Risk
Risk ● Andrew may be at some risk of injury if left unattended when making his way to the bathroom. Prevention ● Andrew should be given assistance as required for him to make his way to the bathroom and maintain his personal hygiene and promote wellbeing. Assistance Required
(Completely independant)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin
General Some assistance is needed for Andrew to choose appropriate quantities of food and liquids. Carers should encourage Andrew to choose appropriately for his diet. Andrew is able to use food utensils without any assistance but he may require some assistance to cut his food into appropriate sized pieces for his consumption. Carers should try to make sure that his food is proportioned sufficiently, reducing any risk. Andrew does not require any specially adapted utensils to consume food or liquids. Diet Without assistance Andrew may not maintain a healthy balanced diet. Carers should encourage him to maintain a healthy diet. Andrew requires occasional encouragement to amend his diet to promote weight control. Carers can assist by encouraging him to amend his diet accordingly. Andrew has religious beliefs but they do not effect his diet. Degree of risk:
Moderate Risk
Risk ● Andrew may be at some risk if he does not have sufficient assistance when selecting appropriate quantities of foods and liquids. ● Andrew may be at some risk if he does not have sufficient assistance to cut his food into appropriate sized pieces for his consumption. ● Andrew may be at some risk as he might have some difficulties with swallowing food. ● Andrew is at risk of not maintaining a healthy balanced diet without assistance. ● Andrew is at risk as he does not maintain a healthy balanced diet. ● Andrew is at risk of losing or gaining weight if not given occasional encouragement regarding his diet. Prevention ● Some assistance could be given to Andrew when he is selecting appropriate quantities of food and liquids. ● Andrew may require his food to be cut into appropriate sized pieces for his consumption. ● Frequent encouragement should be given to Andrew to assist him in maintaining a healthy balanced diet. ● Andrew could be given occasional encouragement to amend his diet to promote weight control. Assistance Required
(Total support)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 17/07/2008 by Admin (RCPD)
Urinary Continence Andrew's last urinary continence assessment was conducted on 17 July 2008. At present Andrew is fully urinary continent and does not require any assistance, however this should be reviewed on a regular basis to ensure his needs are met and wellbeing is promoted. Bowel Continence Andrew's last bowel continence assessment was conducted on 17 July 2008. At present Andrew is fully bowel continent and does not require any assistance, however this should be reviewed on a regular basis to ensure his needs are met and wellbeing is promoted. Andrew can occasionally experience diarrhoea, he may require some emotional and physical support in this matter as it may affect Andrew's feelings and sense of wellbeing. Abilities Andrew may require assistance when transferring on and off the toilet, carers should use an appropriate aid to minimise risks. Andrew requires occasional physical assistance when gaining access to the toilet. Andrew may require some support with his personal hygiene after using the toilet, carers should assist him with this matter if and when necessary. Andrew requires very infrequent reminding or prompting to use toilet facilities. Degree of risk:
Low Risk
Risk ● There is some risk of injury if Andrew is not given some assistance when transfering on and off the toilet. ● Andrew is at some risk if he does not have some assistance when accessing the toilet. ● Andrew's personal hygiene may be at risk without some assistance after using the toilet. Prevention ● Carers should give Andrew some physical support when transferring on and off the toilet. ● Andrew may need to be given some additional assistance to access the toilet. ● Andrew should be given some occasional assistance with his personal hygiene after using the toilet. ● Carers should give Andrew infrequent prompting to use toilet facilities. Assistance Required
(Guidance from 1 carer)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 09/09/2008 by Admin (RCPD)
Night Checks Andrew can sometimes venture outside his room at night times, this could put him at risk of injury due to low lighting. Occasional nightmares can be experienced by Andrew, affecting his wellbeing. Carers should try to reassure him and give emotional support when possible. Restlessness at night times can occasionally be experienced by Andrew, this can affect his wellbeing and also make him feel tired during the day. Andrew may be at some risk of injury during the night. Carers should try to ensure that he has a safe environment. This may include providing good lighting. Bed Rails Andrew does not require bed rails fitted to his bed when resting. Degree of risk:
Moderate Risk
Risk ● Andrew may be at risk as he sometimes ventures outside his room at night. ● Andrew's wellbeing may be at risk as he suffers from occasional nightmares. ● Andrew is occasionally restless at night, this may put his sense of wellbeing at risk and he may feel tired during the day. ● Andrew is at some risk of injury during the night. Prevention ● Andrew should be assisted if he sometimes ventures outside his room during the night. ● Andrew should be reassured and emotionally supported if he experiences occasional nightmares. ● Carers should try to create a safe environment for Andrew at night. Assistance Required
(Guidance from 1 carer) Updated on 17/07/2008 by Admin (RCPD)
Environment Control Andrew requires some assistance to control his own environment such as turning lights on and off, or adjusting heating. Carers should assist him when necessary. Andrew requires some assistance with opening and closing windows, as he finds it difficult to use the mechanism. Carers should ensure that he has assistance when opening and closing his windows. Andrew requires occasional assistance when opening, closing, locking and unlocking doors. Carers should ensure that these are checked before he retires to bed and after he wakes up. Degree of risk:
Moderate Risk
Environmental Control continued on page: 13...
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Risk ● Andrew may be at risk if he has difficulties controlling his environment. ● Andrew may be at risk if not given some assistance when opening and closing windows. ● There may be some risk to Andrew if he does not receive some assistance when opening, closing, locking and unlocking doors. Prevention ● Andrew should be given some assistance when controlling his own environment in regards to heating and lighting. ● Andrew should be given some assistance to open and close windows. ● When opening, closing, locking and unlocking doors Andrew should be given some assistance. Assistance Required
(Guidance from 1 carer) Updated on 09/09/2008 by Admin
Verbal Communication Andrew uses speech to communicate with others. Senses Andrew's vision in his left eye is moderate, however the vision in his right eye is good. Andrew's overall vision is moderate, this may put him at risk of injury if he cannot see hazards which may cause an obstruction. Carers should ensure that if he wears a vision aid that he uses it as necessary and they should also give any other assistance that will promote his safety and wellbeing. Andrew uses prescription glasses to increase his visionary perception. Andrew's overall level of hearing is moderate. This may make communication difficult and pose potential risks. When speaking to Andrew it is especially important to speak in a clear and loud voice. It is important to do this with respect and not in a potentially patronising manner. It may also prove useful to reduce background noise and move closer so Andrew can hear clearly. Andrew may be unable to hear alarms or someone trying to identify a danger, it is important to identify this factor when conducting risk assessments. Andrew's level of hearing in his left ear is good but the level of hearing in his right ear is moderate. Andrew uses a hearing aid to increase his audio perception. When last assessed Andrew's overall level of perception via touch was found to be very good. Cognition Currently Andrew is able to fully understand what is spoken to him.
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 17/07/2008 by Admin (RCPD)
Administration Some assistance or prompting may be necessary for Andrew to remember to take his medication, it is important for carers to remind him to take his medication when prescribed. Andrew does not suffer any known pharmaceutical allergies. A medication risk assessment has been completed for Andrew. Degree of risk:
Moderate Risk
Risk ● Andrew may be at some risk if he is not reminded occasionally to take his medication. Prevention ● Andrew occasionally needs to be reminded to take his medication. ● A medication risk assessment should be kept up to date and current for Andrew's safety. Assistance Required
(Guidance from 1 carer) Updated on 17/07/2008 by Admin (RCPD)
Oral Health Currently Andrew is able to maintain his teeth and oral hygiene independently. Updated on 17/07/2008 by Admin (RCPD)
Social Andrew is currently able to have a full understanding of who is visiting when family and friends visit him. Andrew does not require any assistance when socialising with friends, family and visitors. Emotional Andrew does not currently show any signs or symptoms of emotional health problems. Degree of risk:
Low Risk
Risk ● Andrew is at low risk as he fully understands who is visiting when family and friends come to visit. ● Andrew is at low risk as he does not require any assistance when friends and family visit. ● Andrew is at low risk as he does not show any signs or symptoms of emotional health problems. Emotional Needs continued on page: 15...
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Prevention ● Andrew should continue to be monitored in case he requires assistance when socialising with family and friends in the future. ● Even though currently Andrew shows no signs of emotional health problems he should continue to be monitored in case this situation changes. Assistance Required
(Completely independant) Updated on 17/07/2008 by Admin (RCPD)
Religious Needs Andrew is Christian. Language Andrew's native language is English Updated on 17/07/2008 by Admin (RCPD)
Outings Currently no factors impact upon Andrew's safe enjoyment of external outings or events. General Interests Andrew sometimes requires assistance to participate in entertainment activities inside the home, carers should assist him when necessary as this would improve his safety. Andrew can occasionally lose interest in entertainment activities more quickly than most, this may be due to the type of activity or other reasons, carers should try to identify these reasons and act accordingly to improve Andrew's enjoyment. Updated on 26/08/2008 by Admin
Overview To be entered manually...
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Updated on 17/07/2008 by Admin (RCPD)
Preferences Andrew's last wishes were discussed on 17 July 2008, when it was concluded that he was willing to discuss and record his last wishes. Should Andrew experience a life threatening condition he wishes not to have medical aid to assist recovery. In the event of him experiencing a terminal condition he wishes to reside at the current residence. If his health deteriorates beyond the homes capacity to provide effective care he wishes to transfer to a more effective care environment. He does not have any funeral arrangements in place. Andrew already has last will arrangements in place. He wishes his next of kin to be contacted in such circumstances. He does not wish for his body to be donated to health or scientific facilities. Andrew is willing to review his last wishes again in the future. Updated on 14/05/2008 by Admin
Demo Residential Home, based on the needs assessed within this care plan, confirms the individuals needs can be encompassed safely and effectively within our home environment and the care we provide. Should the individuals needs change this care plan will be reviewed to ensure the individuals well-being is maintained. Managers Signature/Date:________________________________________
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
The purpose of this document is to ensure Andrew’s needs are always accurately reflected within this care plan. Although a full review/re-assessment is conducted at least every 6 months; this process ensures that any minor alterations are recorded so information held in this file is as current as possible and to ensure a review is prompted should any major needs require immediate reassessment. This review process is also a legal requirement in compliance with CSCI standard 7.4.
Last Care Plan Full Review: Next Full Review Due:
20 June 2008 December 2008
No amendments required at current time (Current copy in place) Minor amendments required (Amendment made to computer/paper copy) Major amendments necessary (Full review required) Name:________________________Signature:______________________ Date:__________
No amendments required at current time (Current copy in place) Minor amendments required (Amendment made to computer/paper copy) Major amendments necessary (Full review required) Name:________________________Signature:______________________ Date:__________
No amendments required at current time (Current copy in place) Minor amendments required (Amendment made to computer/paper copy) Major amendments necessary (Full review required) Name:________________________Signature:______________________ Date:__________
No amendments required at current time (Current copy in place) Minor amendments required (Amendment made to computer/paper copy) Major amendments necessary (Full review required) Name:________________________Signature:______________________ Date:__________
No amendments required at current time (Current copy in place) Minor amendments required (Amendment made to computer/paper copy) Major amendments necessary (Full review required) Name:________________________Signature:______________________ Date:__________ Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Instructions: Start Date: Notes: Further information:
ONE to be taken EVERY DAY 01/01/2008 Stop Date: Aspirin is used to relieve mild to moderate pain; reduce fever, redness, and swelling; and to help prevent blood from clotting. It is used to relieve discomfort caused by numerous medical problems, including headache, infections, and arthritis. It is also used to reduce the risk of a second heart attack or stroke. Larger doses of aspirin are used to treat gout.
Instructions:
ONE to be taken TWICE A DAY
Start Date: Notes: Further information:
09/06/2008
Instructions: Start Date: Notes: Further information:
Instructions: Start Date: Notes: Further information:
Instructions: Start Date: Notes: Further information:
Stop Date:
Atenolol is used alone or in combination with other medications to treat high blood pressure. It also is used to prevent angina (chest pain) and treat heart attacks. Atenolol is in a class of medications called beta blockers. It works by slowing the heart rate and relaxing the blood vessels so the heart does not have to pump as hard.
ONE to be taken AT NIGHT 09/06/2008 Stop Date: Corticosteroids are inhaled to help prevent asthma attacks and to ease breathing problems. They work by reducing swelling and irritation in the small air passages of the lungs.
ONE to be taken EVERY DAY 11/06/2008 Stop Date: Bisoprolol is used alone or in combination with other medications to treat high blood pressure. Bisoprolol is in a class of medications called beta blockers. It works by slowing the heart rate and relaxing the blood vessels so the heart does not have to pump as hard.
ONE to be taken TWICE A DAY 01/01/2008 Stop Date: Calcium supplements are taken by individuals who are unable to get enough calcium in their regular diet or who have a need for more calcium. They are used to prevent or treat several conditions that may cause hypocalcemia (not enough calcium in the blood). The body needs calcium to make strong bones. Calcium is also needed for the heart, muscles, and nervous system to work properly.
75 Kg
71 Kg
67 Kg
63 Kg
59 Kg
* Average 55 Kg
51 Kg
47 Kg
43 Kg
39 Kg 1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
19
1 2 3
02/01/2008 08/01/2008 15/01/2008
57 Kg (8st 14lb) 56 Kg (8st 11lb) 56 Kg (8st 11lb)
20 21
4 5 6 7 8
22/01/2008 29/01/2008 05/02/2008 12/02/2008 19/02/2008
56.5 Kg (8st 13lb) 56.8 Kg (8st 13lb) 57 Kg (8st 14lb) 57.9 Kg (9st 2lb) 58.1 Kg (9st 2lb)
22 23 24 25 26
9 10 11
26/02/2008 04/03/2008 11/03/2008
58 Kg (9st 2lb) 57.2 Kg (9st 0lb) 56.1 Kg (8st 12lb)
27 28 29
12 13 14 15 16
18/03/2008 25/03/2008 01/04/2008 08/04/2008 15/04/2008
55.9 Kg (8st 11lb) 56 Kg (8st 11lb) 56.2 Kg (8st 12lb) 56.5 Kg (8st 13lb) 56.4 Kg (8st 12lb)
30 31 32 33 34
17 18
22/04/2008 29/04/2008
56.8 Kg (8st 13lb) 57.1 Kg (8st 14lb)
35 36
03/06/2008
58 Kg (9st 2lb)
Relationship: Home Telephone:
Friend 0151 6287384
Address:
Union Street Hoylake Wirral CH47 7TU
Mobile Telephone:
07870 573 885
Relationship: Home Telephone:
Friend 01275 583 493
Address:
123 Station Road Portishead Bristol BS20 3ER
Relationship:
GP
Address:
Business Telephone:
01234 567 890
Local Health Centre 99 North Road Town Name Postcode
Relationship: Home Telephone: Mobile Telephone:
Son 01792 665 423 07870 486 939
Address:
3 Danygraig Road Swansea Wales SA2 3NT
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Cod and chips Roast dinner Mashed potato
Curry Sweed Cheesecake
Chess Cards Bowls Group outings
Watching Tv
Get up early and have tea
Going to bed late
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Weight:
58 kg
Height:
1.55 meters
1.90m
1.85m
1.80m
1.75m
1.70m
1.65m
1.60m
1.55m
1.50m
1.45m 40kg
50kg
60kg
70kg
80kg
90kg
100kg 110kg 120kg 130kg 140kg
BMI under 20; under weight BMI 20 to 25; ideal weight BMI 25 to 30; over weight BMI 30 to 40; obese BMI 40 and over; very obese Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
5/10
General - (Residents rights and data protection)
2/10 7/10 9/10 7/10 7/10
General - (Dementia overview) Symptoms - (Symptoms of dementia) Emotional - (Emotional needs relating to dementia) Confusion - (Confusion) Memory loss - (Memory loss)
10/10 N/A N/A N/A 10/10 N/A
General - (Signs of abuse) Physical - (Signs of physical abuse) Emotional - (Signs of emotional abuse) Financial - (Signs of financial abuse) Neglect - (Signs of neglect) Sexual - (Signs of sexual abuse)
8/10 8/10 10/10 10/10 10/10 7/10
General - (Overview of health) Tissue Viability - (General tissue health) Strokes - (Health Related to Strokes) Respiratory - (Health related to respiratory) Heart - (Health related to heart) Diabetic - (Diabetic need)
8/10 7/10 7/10 9/10 10/10 6/10
General - (Overview of mobility) Physical Ability - (Physical abilities with regard to mobility) Mobility Aid Use - (Aid used to mobilise) Assistance Required - (Assistance and guidance required) Falls / Risks - (Indentify areas of risk regarding mobility) Orientation - (Orientation, Attitude)
9/10
General - (Overview of mobility outside)
10/10
General - (Overview of transfers)
10/10 10/10 N/A 10/10
General - (General dressing ability) Choice - (Clothing choice) Clothing Items - (Clothing items) Risk - (Dressing risk)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
7/10 6/10 10/10
General - (Personal care overview) Daily Wash - (Daily washing needs) Risk - (Risk of injuries)
9/10
General - (General bathing)
7/10 7/10 10/10
General - (General appetite) Diet - (Diet) Risks - (Risks at mealtimes)
10/10 9/10 7/10
Urine - (Urine continence) Bowel - (Bowel continence) Abilities - (Abilities)
7/10 10/10
General - (Night check risks) Bed Rails - (Use of bed rails)
8/10
General - (Environmental control)
10/10 7/10 10/10 7/10 10/10
Communication - (General communication) Eyesight - (Eyesight) Touch - (Sense of touch) Hearing - (Hearing) Cognition - (General cognition)
9/10 10/10
General - (Medication overview) Risks - (Medication risks)
10/10
General - (Oral health overview)
10/10 10/10
General - (General emotional needs) Emotional - (Emotional related health)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
10/10
General - (General religion and languages)
10/10 9/10
Outings - (External events, performances, theatre) General Interests - (Visual and audio entertainment)
10/10
General - (General palliative care arrangements)
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
02 July 2008 - Dentist - Shirehampton Dentists Andrew had a checkup at the local dentists. Dentist said everything was fine and booked an appointment in six months time.
02 July 2008 - Hairdresser - home Andrew had his hair washed and cut by the visiting hairdresser.
05 July 2008 - Dinner Outing Andrew had a dinner outing with his son Stephen Jones. Andrew had a good time and enjoyed the meal.
07 July 2008 - Telephone Call - home Andrew received a telephone call from his Friend Jason Cooper.
11 July 2008 - Telephone Call - home Andrew received a telephone call from his son Stephen Jones.
16 July 2008 @ 10:45 - Doctor Visit Dr Green visited to check up on Andrew. Dr Green recommended that he should have some blood tests taken.
23 July 2008 @ 13:30 - Blood Test - BRI Andrew was taken to the BRI to have some blood tests taken. Andrew will receive the results in a few weeks.
25 July 2008 - Reminder Andrew requested to be reminded to call his friend Jason Cooper today.
Printed by CareDocs Demonstration (Admin) on 17/09/2008 at 09:28 for Andrew Mark Jones
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