Current social situation, who they live with, any dependents

Current
Social Situation
(Give details of the patients current social situation, who they live with,
any dependents (including pets), what type of accommodation they have and
whether they are having difficulty with this accommodation)
Mrs Violet Smith is an 82 year old
elderly woman who since the death of her husband has living alone, by herself
in a first floor flat, with her pet cat that keeps her company. She has a
daughter named eve who lives not too far from her and only visits twice a
week. Mrs Smith has been in good health up until the recent fall that she
had. Mrs Smith does have high blood pressure, medication has been prescribed
by her General Practitioner. It has been noted that Mrs Smith weight has
dropped by 4kg, going from 60kg to 56kg.
 
 
 
 

Suitability
of Accommodation
(give details about access to the accommodation,  whether there are stairs, are bathrooms and
toilets are up or downstairs etc) 
Accessibility in Mrs Smiths apartment is
quite feasible as everything is on one floor, her bathroom is near her bedroom
and the bedroom is opposite her kitchen and lounge area, however she does not
have bed rail to help her get of bed, since her apartment is an open plan.
 
 
 

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Current
or Previous Occupation (if retired)
 

 

Does
the patient receive care from either social services or an unpaid carer?  YES     
NO          (if yes give
details)
Carers name and telephone number
Eve
Type of care given
Her daughter Eve comes in twice a week to help
Violet with her medication and helps to manage all her affairs including her meals
finances.
Does this key need reviewing?
This key does to be need reviewed as Mrs Smith
suspects that her daughter Eve has access to her accounts and is using her
savings for own financial gain.

 

Patient Name

NHS Number: 4876334531

Patients understanding of their condition and
diagnosis
Mrs Smith has an understanding of her current
condition and how her mobility will be affected due to her fall, however she
does not have a clear understanding of the reason that she should be taking
her blood pressure medication.
 

Behaviour
(consider whether there are any types/ patterns or triggers for behaviour and
their frequency)

During the visit to Mrs Smiths’ home, she was very
sociable and had no problem speaking to me about her concerns that bothered
her. However, when the conversation would move towards her late husband
raised about her husband she would become closed off and the conversation
would come to a halt.

Cognition
(consider the ability to make decisions, mental capacity, is someone acting
as a power of attorney, assessed for capacity?)

Whilst the care plan was being written Mrs Smith
seemed to be capable of making her own decisions as she has shown that she
has an understanding of her current condition, and is aware of the changes
that may need to be made in order to make her current living situation more
feasible and safer for her.  Mrs Smith
also told me about how sometimes she would forget to take her medication for
blood pressure.

Psychological/
emotional needs (including distress, anxiety,
depression)

During the visit that Mrs Smith spoke about how she
feels that she does not have control over her life and has been feeling very
distressed and alone since the death of her husband. But she has her cat to
keep her company.

Communication
(including
expression of needs, non-verbal and verbal communication, hearing, sight etc)

Mrs Smith has good eyesight and she does not wear
hearing aids. She has shown that she can communicate well verbally and does
not need any additional help when it comes to verbal and non-verbal
communication as she is expressive through her body language.
 

Mobility
(describe
the patients actual abilities and difficulties, transfers, aides used or
required, inc M and falls assessment

Mrs Smith stated that it takes her about three
attempts to stand up from her arm chair, and that she feels unstable when
getting up from her arm chair, she feels that she would need extra support
when she uses the walking stick that her late husband used as she is shaky
and unsteady on her feet.
 
 
 
 
 

Patient Name

NHS Number: 4876334531

Nutrition
(Inc BMI, MUST, ability to maintain their own nutritional and hydration
status)

It has been documented Mrs Smith’s weight has
dropped from 60kg to 56kg in the past three months, she fears that she may
lose more weight if something isn’t sorted out for her, and she also stated
that she has been feeling a loss of appetite and that she only eats in the
evening but even then she does not finish her food. Even though her daughter
has food delivered to her home from the local supermarket she finds it
difficult to prepare meals dues to her recent fall. As she is fearful that
she may fall over while preparing her meals. Also Mrs Smith said that her
daughter does not get foods that she likes, which does not make her motivated
to make her own meals and she also prefers ready-made meals.  

Elimination
(inc continence issues, bowel pattern and any changes)   

Mrs Smith occasionally wears stress incontinence
pads, she said that she does not like to wear too often as her bathroom in on
the same floor, she stated that she has not noticed any changes in her bowel
movement.

Skin
care ( inc. condition of skin, pressure area assessment,
waterlow score)

Mrs Smith seemed as though she was well hydrated,
her lips were not dry, and she did not have pressure sores.
 

Breathing
(inc
respiratory rate, difficulties with breathing etc)

Mrs Smiths has a respiratory rate of 12, so her breathing
rate was normal and showed no difficulties with breathing.
 

Medications
(inc
what medications is your patient receiving? Any difficulties with medication)

Mrs Smith is taking 5mg of amlodipine as she has
hypertension that helps to lower her blood pressure. She has not stated if
she has any difficulties with the medication apart from forgetting to take
the medication from time to time, but as of recently she has been feeling
lightheaded but is uncertain if the medication is the cause of this.

Maintaining
safe environment (is your patient able to maintain their
own safety?)

Mrs Smith feels as though she may not be able to
maintain her own safety in her own home because she is scared of falling over
again, although she has a walking stick to help her go around her apartment.
She also fears burning herself while she is cooking. During the visit I
noticed that there were some tripping hazards in her home such as wires not
being plugged in properly and they were in the pathway.

Sexuality
(does
your patient have any concerns about their sexuality or sexual health?)

Mrs Smith has stated that she is not happy with her
appearance, which includes her body shape and is unable to wear her nicer and
smarter clothes because of this she feels as though she looks unkempt and
feels embarrassed to go out because she is not confident in her appearance
 

Patient Name

NHS Number: 4876334531

Personal
care (inc how does your patient maintain their own
personal care, what assistance is required?)

Mrs Smith has a strip bath in her bathroom sink
every morning, she does not need assistance when she is dressing herself
however she says that is does take her a while to get ready.
 
 
 

Sleeping
(for
example sleep pattern, and issues with sleeping)

Mrs Smith has stated that she does not sleep well at
night, she says that she only sleeps for three hours and wakes up every half
an hour and is really tired throughout the day, but she has naps during the
day if she is feeling tired.
 

Dying
(does
your patient have any concerns or questions about their illness?)

Mrs Smith misses her late husband who died from
bowel cancer. Since there was a delay in obtaining his medical assessments
she witnessed the deterioration in his health, she is scared that she may face
the same fate as her husband, as she thinks that weight loss, light-headedness
and the recent fall that she just had may be signs of cancer. Although Mrs
Smith has stated that she is not suicidal, she says that she would not mind
in joining her husband.
 
 

Spirituality
(do
they require any spiritual support)

As Mrs Smith’s husband had died three years ago, she
would attend church on Sundays with friends, she decided to stop going as she
would feel dizzy and light headed when the congregation had to stand up
during the service. Up until recently she use to attend coffee morning on
Thursday at the church but decided to stop because she is fearful of falling
in the churches hall. Mrs Smith does not require spiritual support as the
priest of her church comes to visit her every Thursday evening to give her
words of encouragement, prayer points and bible verses to read during the
week since she had stopped going to church.

 

Nursing
Care Plan – original to be retained by the patient

Patients Name                                                                                                 NHS
Number: 4876334531                                                                            Date

Identified Patient Problem

Goals

Interventions

Evaluation Date

Mobility

The goal is that Mrs Smith has walking aids
installed in her apartment. Also for her to be steadier on her feet while
using a walking stick.

Mrs Smith is unsteady on her feet and her expressed
difficulties in using the walking stick of her late husband and how she feels
uneasy when using it. She has stated that she would like walking stick that
is custom for her, as her she would feel more secure if there was a few
walking rails installed within her apartment. 
She can be referred to a team of occupational therapists and the
physiotherapists by her General practitioner who can work together in order
to make movement for violet in her how apartment less stressful that the
occupation therapy team would be able to carry out a number of risk
assessments in her home, to if she is legible for walking aids to be
installed inside her home. The physiotherapist can come and visit at least
twice a week to get her to her baseline which may help her in becoming more
confident in going back to the activities that she use to carry out before
her fall.

 
 
 
 
 
 
 
 
 
 
 
 
 
 

Nurses Name

Signature

Date

 

Patients Name                                                                                                 NHS
Number: 4876334531                                                    Date

Identified Patient Problem

Goals

Interventions

Evaluation Date

Nutrition

The goal would be to get her to eat three meals a
day, for them to be portioned out evenly.

The General Practitioner can refer Mrs Smith to a
dietitian, so that they can discuss and negotiate a meal plan for her. Mrs
Smith’s daughter Eve can be brought into the planning of the meal plans as
she is the one that takes care of her mother’s grocery shopping, they could
discuss what food items can be bought in order to for her to be able to cook
the meals that she wants would like to eat for herself. The Dietitian would
be able to give Mrs Smith advice and counselling about what would be good for
her diet and her daily nutritional intake, and making sure that she has a
good intake of carbohydrates, proteins, fats, minerals, vitamins, fibres and
water so that she well hydrated. It would be beneficial for her to have a
dietitian due to experiencing weight loss in the past three months, the dietitian
can help her get back to healthier weight.