Outline  what assessment ,( Mental and physical) you would need to complete on Mr Bree

What Assessment:  Height, weight, Allergy and VTE assessment

4At Assessment for cognition and delirium

Fall Risk Assessment Tool (FRAT)

Patient Handling Risk assesment

Humpty Fall assessment Tool                                                                                                                                                                                                                                                                                                                                                                                                            Falls Risk  Assessment Tool

Modified Mini mental –status exam

Patient Handling Risk Assesment

Risk assessment screening Tool

Physical: Physical obs such as BP( Postral), Pulse, respiratory, Temp

Neuro logical obs- GCS,BGL, Maintain food and Fluid chart, Pain interventions  Behavior record , Gastro intestinal assessment.

Interventions:

What Intervention are needed for MRS BEE?

Admit 1 West as voluntary patient
1:15 visual obs initially (in setting of unsteady gait on mobilising) with view to decrease frequency as guided by ongoing nursing risk assessments ( if attempts to leave prior to review place on AO)
PRN Medication Charted
Currently withholding antipsychotic medication For example quetiapine given patient’s complaints of dizziness whilst on quetiapine and mildly unsteady on mobilising currently
– treating team to review this ?restart vs alternative
PRN and Regular Medication Charted
Admission bloods – added on TFTs, Vit D, Vit B12, folate
Baseline ECG and UDS
Postural BP BD
Falls prevention
Collateral from patient’s private psychologist/GP (patient consenting to both)

Commence Mental Health Treatment Plan

Regular update to assisted living facility and NOK

What could Mr Bee current diagnosis be:

Alzheimers dementia ?

Who is going to be involved in the care of Mrs Bree

Medical staff( Consultant Psychiatrist,  Psychiatric Registrar & HMO) will supervise overall recovery and will diagnosis the client condition and prescribed suitable treatment – including Charted Regular and PRN’s Medication, Order cognitive screen .

Nursing Staff: Nursing staff provide both physical and mental  nursing care and send referral to Community Nursing Team such as ACAS( Aged Care Assessment Service and APICATT community Follow up

Social worker

Occupational Therapist

Psychologist

Family

Risk Factor:

Vulnerability and deterioration from high stimulus

Difficult with information gathering from very limited collateral sources, affecting the formulation

Further deterioration in Physical and Mental health and self-neglect unless treated

High Falls 

Overarching “rules”- avoid overly clinical language. This is the young person’s story and record of their stay so avoid judgemental or triggering language including reference to sexual assault (our trauma informed service includes language in reports- refer to “trauma history” or equiv)

Keep it strengths based.

Consider it like a school report- inclusive, positive framing about the work done, but with relevant info for the next clinical service to understand the admission.

Respect the person’s pronouns and gender identity

Start at admission and add to it through the stay

Check that the Dx is the one confirmed with the Consultant and has been discussed with the young person before adding it to the summary

Summary to the aged person at the time of DC, and to the GP and any other clinical support service.

Formulation:

Do not copy/paste from another place, but you can use the info to develop your own description

Think about the 5 “P”s

Presenting– This is a brief introduction of the young person, demographics -where do they live, with whom, ?work, ?school, ?centrelink etc- and how they came to be referred to Y-PARC.

 Precipitating- what happened?

predisposing -AOD, genetic vulnerability, attachment issues, trauma etc,

protective- what keeps them going, strengths?, positive self image, future plan etc,

perpetuating-AOD use, homelessness, not ready to do what needs to be done, PTSD, family violence etc

• Goals for stay at in- patient unit:  Improve self-worth and self esteem
• Improving independent living skills
• Coping skills ?????

Treatment:

Include daily  report to demonstrate progress/trajectory. If someone has been here for several weeks there should be quite a bit to report.

What were they good at? What did they struggle with? How did they respond to challenges? How did we support them to apply their strengths to their struggles? Social interactions, group participation, independent living skills etc.

This needs to be personalised

Imagine you are receiving feedback about your work performance- how would you like that delivered?

Referrals/ psychiatrist reviews/ psychologist, AOD, SW, OT input.

Follow up recommendations:

Who is doing the follow up?

Any recommendations re medications or referrals by others (eg GP)

Recommendations for readmission in the future?

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