Microsoft word - marie in hospital profile ver4.rtf

‘Observation’ and 'Communication’ Models ‘Marie’ Hospital Profile
Patient details

Mrs Marie Browne DOB ……………Her husband died …………. aged 90Temporary resident with her son .……….
Phone: ……………………NHS NO …………….
GP Dr. ………
Address: ……………………………. ………… …………
Phone: …………………. Fax : ………………….
Past medical history
Atrial fibrillation, Hypertension, raised cholesterol, diverticulitis,
vaginal hysterectomy, bladder repair, cholecystectomy, fractured neck
of femur Aug 06, removal of variety of skin leisions.
Frail skin of legs due to long term use of steroid cream.
31/7/08 Heart attack - Mild damage left ventricle
22/8/07 Admitted with chest pain. Nothing conclusive.
AF not for years
Sotalol reduced 3 m ago.
Stopped - Sotalol hydrochloride 40 mgs twice daily and Ramapril 5 mgs daily
Current Medication
Glycerine Trinitrate Spray
Ramapril 2.5 mgs daily
Lipitor Atorvastatin 20mgs at night
Calcichew-D3 Forte Chewable tablets one tablet twice daily
75 Mg Asperin one daily
75Mg Clopidogrel
Omeprazole 20mgs every day
Alendronic Acid 70mg on Mondays
Temazepam 10mgs at night
Movicol Sachets twice daily as required.
Does not wish to be resuscitated.
Social History
Marie had five children and many grandchildren.
She lived with her daughter for the last year.
Socialising always has been and remains very important to Marie.
Having had a second hip fracture she has not mobilised after the operation.
Observation Model
Things that cause emotional distress
She is a strong willed and determined woman with a very poor short-term memory who becomes distressed
if what she wishes to happen is frustrated in any way.
She only engages with people she accepts and only interacts with them on her own terms.
Because her short-term memory is failing, her motivation to and recollection of the need to do things ispoor.
She is often disorientated in place and time.
She needs to be prompted to do things in her life – which she often refuses. Other thing can then be suggested till she gets to the point of making a decision – often to do nothing - or sleep.
Page 1 Derek Browne & Associates QA and Care Planning in Dementia Care Licensed use of material Derek Browne May ‘09.
1 Reassuring factors
She is a very sociable person and when not engaged in meaningful activity needs company to reassure her.
She likes to hear the world going by her bed.
2 Dislikes
Dislikes being prompted to do things that are good for her - she knows her own mind.
She can make critical remarks about services provided.
Her distress or lack of meaningful occupation needs to be observed in her face, as she is often unable toarticulate what is not positive in her world.
3 Discussion topics
She loves to talk about her early life and her children and how she had to chase her sons around the yard totry to smack them – because they were so bold.
She can be asked to tell people about her past life:-• When Marie was little she and her sister Eva put their cat Tom in a pram and he would suck on a bottle. He would tuck his pawties under the blanket. Eva says that Tom used to get his own back bychewing up the teat.
• When Alan was 6 he found a dead rat and chased Marie across the garden with it - she denies jumping • She stayed in bed with Rusty the cat and paid 1p to Derek so that she could have breakfast in bed.
• When the boys were small she allowed Geoff to give the top of the milk to Rusty the cat and didn't mind As her memory is poor she can repeat the same stories, but is easily encouraged to move on to a new story.
She has liked to play Scrabble with her son Derek. Sometimes she gets upset if she does not win andsometimes she does not mind.
4 Independent activities on own
She likes to stay in bed when she feels unwell.
She can be reminded and supported in:-• Watching the Photo Box.
• Listening to the news.
• Listening to light classical music softly playing in the background.
• Reading the Times (Monday to Saturday) and on Sunday the Telegraph. Reading magazines.
She loves to pet and stroke cats and dogs. 5 Independent activities with other Patients
She likes to engage with patients in other beds. 6 Calming Techniques
7 Food and drink preferences
Eats poorly. Likes grapes, yoghurt, ice cream, soup.
She likes a cup of tea or coffee.
Needs to be supplied with beakers of water with a straw and prompted to drink.
Her tastes vary a lot and sometimes she likes lemonade or soda water.
8 Socialisation at mealtimes
9 Personal care preferences
Needs full support in toileting and dressing.
Gets distressed when she senses staff consider her a nuisance and becomes withdrawn when thishappens.
Page 2 Derek Browne & Associates QA and Care Planning in Dementia C


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