Problem
Mr. M is a 70 year old sergeant from the Jamaican army who stands 6ft inches tall. He was diagnosed with Alzheimer's Disease approximately 3 years ago. Mr. M has been living at XYZ Long Term Care Home for about three months. Prior to being admitted, Mr. M wandered away from his home on several occasions and needed support from the police to be returned. Mr. M rises from bed at 0630 each morning and is awake all day, until he goes to bed at 2100 hours. Even though he uses a cane to walk, he showers and dresses himself independently; he takes great pride in his appearance. Mr. M prefers to eat at a table on his own and despite attempts made by staff to invite him to church service and to various music-related activities, he has not attended any of the leisure activities planned by the recreation department. According to his wife, who seems increasingly worn out when she visits, Mr. M has always been a very social and active individual. Throughout the course of his life, he was always a leader in his community and involved in his church. He played the steel drums as a young man living in Jamaica and has continued to love music and dancing - in particular with his wife, for as long as she has known him: 40 years. Mrs. M is surprised and concerned to hear her husband has withdrawn from activities completely and chooses to sit on a chair in the dining room for much of the day.
Read this case study and do these tasks
Assess Mr. M to identify problem/area of need. Determine risk factors and complications of the problem/area of need. Make a focus statement for the care plan. Make a Specific-Measurable-Attainable-Realistic-Timed goal for Mr. M.
List interventions needed to reach the goal. Make a progress note for your care plan.
The Progress Note
Write a DAP progress note outlining your care planning for your resident. (What do you want the interdisciplinary team to know about the findings of your assessment, your choices and how you intend to maximize the quality of life and quality of care for your resident?)