Download KAW Care Plan Example - SHINE

Last
Updated
July 09
NORTHERN
HEALTH
AFFIX PATIENT IDENTIFICATION LABEL HERE
U.R. NUMBER: __________________________________________________
SURNAME: ____________________________________________________
CHANGED BEHAVIOUR
PERSONALISED CARE PLAN
GIVEN NAME: ____________________________________________________
DATE OF BIRTH: _______/_______/_______ SEX: _______________________
Date:
Social:
86 yo Male Admitted to KAW Aged following failed admission to LLC at Anzac Logde. Patient Admitted with Dementia with BPSD. PHx of Vascular
Dementia, IHD, HTN, Hyperlipidaemia, BPH, Falls, Osteoporosis. Discharge plan for patient for HLC Dementia Specific/Sensitive.
Needs Identified
Contributing Factors
Care Intervention
Review Date
(C) Completed
Please Initial
1. Communication
At Risk of not making needs understood
2.Mobility
At Risk of Injury/ High Falls
Risk/Wandering
3.Nutrition/Hydration
Potential for reduced/decreased Diet
and fluid Intake
-
Unpredictable
Behaviours/Aggression
Lack of Insight
NESB- Italian speaking(very Mini
Dysphasia
-
Speak in short concise sentences and questions
Give patient time to speak and respond.
Use Body Language and Hand gestures
Patient responds well to positive body language- i.e.
smiles
-
Multiple Falls in the Past
Lack of Insight
Impulsiveness
-
Ensure patient is closely supervised
If Available use Bed and Chair Alarms
Ensure Hip Protectors Insitu
At times when patient wants to wander, monitor patient
from a distance, as advising him to sit down or redirection
will exacerbate his behaviour.
-
Lack of Insight
Poor eye sight
-
Encourage patient to sit down and eat. Prefers quiet
areas.
Ensure patient is set-up and directed during meals. may
require feeding/meal assistance
Prefers small meals.
Like toast/ bread rolls and tea as a meal replacement on
occasions. Or sweet foods with medication
-
-
7/11/12
To see if
interventions
Are affective
2/52 post
admission to
new facility
7/11/12
To see if
interventions
Are affective
2/52 post
admission to
new facility
7/11/12
To see if
interventions
Are
affective
2/52 post
admission
Needs Identified
Contributing Factors
Care Intervention
Review Date
(C) Completed
Please Initial
4.Personal Hygiene
Unable to manage personal hygiene
and ADL’s
-
Lack of Insight
Poor eye sight
Unpredictable
Behaviours/Aggression
-
5.Toileting
Unable to Manage Toilet/Occasionally
Voids and defecates Inappropriately
6. Medications
Inability to manage medication and
understand the reasoning for the need
of taking medications
-
-
-
Lack of Insight
Poor eye sight/Poor recognition of
toileting facilities
Unpredictable
Behaviours/Aggression
-
Lack Of Insight
Poor concentration/ Cognitive
Impairment
-
-
Ensure minimum of 2 staff to attend to all hygiene and
ADL’s. Pt can hit out and be resistive during this time.
Explain to patient every step; Patient doesn’t like to be
rushed.
Patient is showered Twice Weekly
Ensure minimum of 2 staff to attend to all hygiene and
ADL’s. Pt can hit out during this time.
Explain to patient every step; Patient doesn’t like to be
rushed.
Pt is incontinent of urine and faeces, wears incontinence
aids. Encourage a regular toileting Regime
Medication must be crushed and mixed/ hidden in
Tea/Drinks/Food. Patient must not see staff do this.
to new
facility
7/11/12
To see if
interventions
Are
affective
2/52 post
admission
to new
facility
7/11/12
To see if
interventions
Are affective
2/52 post
admission to
new facility
7/11/12
To see if
interventions
Are affective
2/52 post
admission to
new facility
Needs Identified
Contributing Factors
Care Intervention
Review Date
(C) Completed
Please Initial
7.Pain Management
At risk of being in pain but not being
able to verbalise.
8.Overnight Care
-
Lack Of Insight
Age and General Condition
-
Age and General Condition
-
Ensure Dark/ Quiet Environment
PRN Medication May be required to settle Patient at Night
Poor sleep pattern over night can be contributed to
patient likes to sleep or will infact doze post meals during
the day.
-
Lack Of Insight
Anxiety and Agitation
Unpredictable
Behaviours/Aggression
-
Ensure patient is closely supervised
If Available use Bed and Chair Alarms
Ensure Hip Protectors Insitu
At times when patient wants to wander, monitor patient
from a distance, as advising him to sit down or redirection
will exacerbate his behaviour.
At risk of Poor Sleep Pattern
- Monitor patient for facial expression of pain and other
body language
- Encourage regular Analgesia, currently on TDS Panadol
Osteo.
7/11/12
To see if
interventions
Are affective
2/52 post
admission to
new facility
7/11/12
To see if
interventions
Are affective
2/52 post
admission to
new facility
Behavioural/Psychological Symptoms
9.Wandering
Pt Wanders Aimlessly into other Patient
rooms.
10.Resistiveness
See Personal Hygiene and Medication
See Personal Hygiene and Medication
See Personal Hygiene and Medication
-
-
7/11/12
To see if
interventions
Are affective
2/52 post
admission to
new facility
N/A
Needs Identified
Contributing Factors
Care Intervention
Review Date
(C) Completed
Please Initial
11.Aggression – verbal/physical
Is Verbally and Physically Aggression
12.Anxiety/Agitation
Has Anxiety and Agitation
-
-
Anxiety and Agitation
Unpredictable
Behaviours/Aggression
Unpredictable
Behaviours/Aggression
-
-
PRN Medication May be required to settle patient
Keep distance and give patient space and time to Calm
Down in quiet environment
PRN Medication May be required to settle patient
Keep distance and give patient space and time to Calm
Down in quiet environment
7/11/12
To see if
interventions
Are affective
2/52 post
admission to
new facility
7/11/12
To see if
interventions
Are affective
2/52 post
admission to
new facility
13.Vocalisation
Nil Displayed
Nil Displayed
N/A
Nil Issues Displayed
14.Hallucination- visual /auditory
Nil Displayed
Nil Displayed
N/A
Nil Displayed
15. Sexual Disinhibition
Nil Displayed
Nil Displayed
N/A
Nil Displayed
Name: Signature
Reference: Dementia Consultation Service NH 2009
Designation:
Date: 28/10/12