ࡱ>  ɀ\phoggag20Soma Ba==xxX/"8X@"1Arial1Arial1Arial1Arial1Verdana1 Arial1$Arial1Verdana1Verdana1Verdana""#,##0;\-""#,##0""#,##0;[Red]\-""#,##0""#,##0.00;\-""#,##0.00#""#,##0.00;[Red]\-""#,##0.005*0_-""* #,##0_-;\-""* #,##0_-;_-""* "-"_-;_-@_-,)'_-* #,##0_-;\-* #,##0_-;_-* "-"_-;_-@_-=,8_-""* #,##0.00_-;\-""* #,##0.00_-;_-""* "-"??_-;_-@_-4+/_-* #,##0.00_-;\-* #,##0.00_-;_-* "-"??_-;_-@_-                + ) , *       (@@  (@  ( @  (@  (  (  (@@  (@  ( @  (@  (  (  (@  ,@ !8@ !8   (@@ !8@  h@   ,@  (@   (@  (@@   (@@  (@@  (@  ( @  (@ @  (  ( "8@ "8 @  `(.Sheet1Sheet2Sheet3,`ifNf8@ZR3  @@   RPreferred name:First Name(s): ElizabethOther Names: AliceDOB: 15/07/16 Title: MrsGender: FemalePermanent Address:26 Longnor Road SomewhereEnglandST6 5NYPresent Location (if different)Ward 7 A HospitalPhone No: 01359 337543ST4 3RJPhone No: 01359 664321Preferred Language: EnglishTenure: Private rented Type: FlatElectric storage heatersPractice Address:Fair Oak SurgeryPhone: 01359 337561Health and safety issues: *Inability to manage storage heating system Arthritis Poor hearingName: Lesley ThomasLast Name: ThomasSonAddress: Contact No: 07786 553472Relationship / Comments:C/o Mr D Brown - friend 13 BlackheathNearbyAnnie Cartwright: Australia Alice Springs20 Settle Road Not knownSister No contact in more than 20 years Key HolderNOKMeals on WheelsFair Oak Drive Contact No: 01359 3375 79 End Date: Start date:District Nurse 01359 337561until admitted Agreement to sharing information[I understand that relevant information from my assessment may be shared with other agenciesainvolved in my care. I agree to my information being shared with them on a need to know basis. Signed:Date:Yes / NoSigned: E A Thomas Date:25/01/05;Permanent or Longstanding Health Conditions or Disabilities/Deafness - Hearing aid supplied in September 01?Arthritis in elbows, hands and knees - diagnosed in November 89Name: Elizabeth Thomas.Interpretation / Communication / Sensory NeedsWears a hearing aid in Left ear%Wears glasses for reading and writingCurrent / Previous Occupation SecretaryBPerson's own perception of needs. Has he / she agreed to referralUCerebral Vascular Accident (Stroke) diagnosed November 03 - weakness down right side [I can't stand up or walk, how am I going to get up the stairs to my flat with my shopping. Lives alone: Yes, with her cat.*I managed all right before this happened. CWho will look after my cat, she will be all alone, and have no food;If only my husband were still alive he would look after me.$Will you help me, I want to go home?+Reason for Referral - views of the referrerhas been identified as a need.Name of Referrer:Contact details: 01359 664321ext 3438,Any Known or potential risks to service userPMoving and handling risks associated with a right sided weakness from the strokeQLeg ulcer on left leg - had been attended to by District Nurse prior to admissionhUnderweight from poor dietary intake, identified on admission to hospital, lack of appetite since stroke*Action taken, including any referrals made]Referrals have been made to the dietician and the Physiotherapist and Occupational Therapist YNurses on the ward have been dressing the leg ulcer, and monitoring fluid and food intakePAdditional Comments, including any recent hospital admissions and dates if known_Admitted to hospital, having been found by son, unconscious on floor in bedroom. A Stroke was :diagnosed on admission. Admitted on 20/11/04 to 25/01/05 Completed By:Contact Details: Current involvement: Ward Nurse Position: Nurse assigned to Patient@Significant Contacts (indicate emergency Contact and main carer) Insufficient dietary intakeAllergies / Intolerance*Professional involved or services provided`If person is unable to give agreement, give details, e.g. reasons and any other people consulted&bElizabeth has indicated a wish to return home, however she has recently been diagnosed as having ahad a stroke which has left her with a dense right sided weakness, which has greatly affected herVmobility and dependency levels. At this present time she has been assessed as needing esupport in all aspects of care within her own home environment. Further assessment from specialists Signature:Accommodation Details4Access details: 6th Floor - lift not always workingWWhat are your hopes at the end of the assessment? What would you like to be able to do?aI want to go home to look after my cat, but I will need to be able to get up the steps to my flat.so I will need to be able to walk by myself. My cat and my walking%What would you like to get help with?*Do you have any concerns about your health$Falls: 2 or more in the last 6monthsYesNO Comments "What if my walking gets no better,What if I have another StrokeNo!When did you last see the Doctor?$Do you have regular tests/check ups?Do you have difficulty in: BreathingWhen I had the Flu I couldn't breathe very wellEating / Drinking!Incontinent of urine since StrokeI don't feel like eatingRecent weight loss noted Swallowing'Unplanned weight loss past 3 - 6 monthsmore since being in hospital Sleep patternSleeps 6 hours per nightPain$From Arthritis in joints especially at end of day!Skin Condition / tissue viability Dry skin - leg ulcer on left leg1cm in diameterContinence - urine / bowels$Incontinent of urine due to mobilityConstipation at timesFoot / Nail Carecommunity every 3 months Oral HealthWears denturesSmoking HistoryAlcohol intakeSmoked when younger has not for past 40 years!Likes Whiskey at night before bed Health Promotion Issues AssessedDo you have any concerns about your safety?Safety Assessment done$I am scared of falling over or down the stairsDifficulty in summoning helpI couldn't get to the phonebecause I can't walk very wellJoint Risk Assessment neededMedication issues assessedDifficulty getting medication out of containers*Don't always take medication as prescribed'Do you take over the counter medicationAndrews Liver Saltssometimes I have forgottenI wouldn't be able to now(Do you need to be reminded to take pills Sometimes5Do you have any difficulty with any of the following:Washing / bathingUsing toilet / commodeDressing / Undressing Keeping warmPreparing food and drinkAny special dietDoing shoppingDoing Housework Doing LaundryI need help from the staff now!I wouldn't be able to do this nowPersonal Care & Domestic needs assessedMobility Issues assessed&Difficulty in getting around the house Difficulty getting out/ into bed'Difficulty in transferring in/out chair%Difficulty getting in/out of property!Difficulty getting up/down stairs)Do you use anything to help your mobilityIn hospital at presentNeeds help from 2N/A at presentUnable to do at presentWheelchair, walking frameSensory Needs assessedSight problemsHearing problemsAny communication needsWears glasses for reading and writingWears hearing aid"Appropriate measures for speaking $Any diagnosed mental health problemsDifficulty with orientation&Difficulty remembering / concentrating Recent LossHusband died 20 years agoFeelings of anxiety/distressWorried about her catFeelings of depressionWants to go homeBlue Badge userAble to access public transportAble to access local shops!Able to access leisure activitiesAble to get in/out of carHeating issuesSecurity issues Key holder / key safe / lifelineDLA / Attendance AllowanceDifficulty managing finances!Power of attorney / appointeeshipFinancial advice needed Environmental Needs / resources Accommodation suitable to needsNone identifiedNot assessed at this time"Client would not be able to manageown care mobility would affect ability to maintain securityson unavailable at timesWould be beneficial&Do you get help regularly from anyone?Do they need support)Are you able to maintain social contacts?Any conflict of views"Carers assessment needed / offeredCultural / spiritual needs(Relationships and carer support assessedNot applicableNot at this present timeAny Additional Information Evaluation1Identified needs and potential for rehabilitationGP's Name: Dr DoolittleAttends Chiropody services in Emotional well-being assessedCurrently mobility hindersCarer involved in a<ssessmentFElizabeth remains adamant that she returns home and appears to have a +motivated positive outlook on her situationFaith: MethodistEthnicity: White BritishHay fever / Penicillin Mrs N WardName: Mrs N Ward#Chest Infection diagnosed in Feb 04and eye sight tests Blood pressure check for high BP Active participation in religionwith a partially deaf personCould not attendWhen well attends church twice per weekXRehabilitation is required in a safe environment to improve current levels of abilities,&with a view to maximising independencePElizabeth has agreed to go to a care setting that provides rehabilitation carer "@ V "  o.  r!7{GI ~J  }IY%5 |!xM"P#<$$%&r'fx(Dl)8f*l+,* ɀ 8>49@/J9RZedMmvIu  dMbP?_*+%6&L&"Arial,Bold"&8鶹 Key Skills: Apprenticeships&C&"Arial,Bold"&8Health and Social Care: Prepared Documentation &R&"Arial,Bold"&8Case History File: Mrs. MooreVS&L&"Arial,Bold"&8http://www.bbc.co.uk/keyskills/apps/&R&"Arial,Bold"&8Page &P of &N&M&d2?'M&d2?(333333?)zG?M\\bbcrp2005\L375124-wc? 3dXLetter.HP LaserJet 4100 PCL 5e2xePjTQ]랓g2D1x}H!F;a8ASj+A0>~hmqL.g:bSIt+|B [w5MkR)XGe#jCOP)p[֊NMFV;Qբ-z>\u+T ]]SIJOntG#|v *9x44T}~}vQS ZJemv6Nh! opo_qؚ Hr@ۆ@y2Pb 7ϥĝ`gǮyNP8sʓ$|p*\lv6^:s~~1=  @ :@ h@ h@     @ Y@ Y@ w@ h@  h@ J@ Y@                .  .  .  0   , "   .  0  0  !""""# ! 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