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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