Adamson Sharon Hebburn Council Hebburn Council NATIONAL CARE RECORDS SERVICE SPINE Claire Osmund Ward 5 Hebburn NHS Trust Hebburn NHS Trust, East View, hebburn, Tyne and Wear, NE31 2TQ

/EASY-Care Self Assessment/1.4 Mrs Audrey Jones Mrs Audrey Jones

Assessment Tool Used: Easy-CARE SAP Overview Assessment Review Date: 25-Sep-2007 Present During Assessment: Mrs Jones' wife - Audrey

My Physical Wellbeing Desired Outcome - Improved Health
My Disabilities, impairments and other Conditions	{{ Not Covered by Assessment tool }}
General Physical Wellbeing	Your well-being In general would you say your health is (Excellent/ Very good/ Good/ Fair/ Poor) Good Additional comments: Had a stroke a few months ago Do you have any problems with your feet? No
Sensory Impairment	Seeing,hearing & communicating Can you see?(with glasses if worn) Yes Can you hear?(with hearing aid if worn) Yes
My Communication Needs	Seeing,hearing & communicating Do you have any difficulty making yourself understood? No difficulty Can you use the telephone? Without help, including looking up numbers and dialling
Medications	Looking After Yourself Can you take your own medication? Without help (in the right doses and at the right time). Additional comments: Wife supervises and puts them into pots. Inhaler technique taught recently by District Nurse - not assessed in A&E.
Lapses of Consciousness	{{ Not Covered by Assessment tool }}
Skin Care/Wound Management	Looking After Yourself Have you had any problems with your skin? Yes Additional comments Currently has whole body itchy rash due to reaction to antibiotics. Prescribed piriton and steroids, advised by A&E to use calamine lotion.
Using the Toilet and Continence	Looking After Yourself Do you have any accidents with your bladder? No accidents Do you have any accidents with your bowels? No accidents Can you use the toilet (or commode)? Without help Additional comments Has Mowbray toilet frame and RTS in toilets at home. Uses a bottle at night.
Breathing	Looking After Your Health Do you get out of breath during normal activities? Yes - On stairs and on the flat and when bathing
Swallowing and My Oral Health	Looking After Yourself Do you have any problems with your mouth or teeth? No
Pain	Your Well-Being Have you had any trouble sleeping in the past month? Yes Additional comments: Feels itchy.
Sleeping	Your Well-Being Have you had much bodily pain in the past month? No

Mental, Psychological and Emotional wellbeing Desired Outcome - Improved Health
My Mental Health Needs	{{ Not Covered by Assessment tool }}
My Behaviour	{{ Not Covered by Assessment tool }}
Memory, Thinking and Reasoning (Cognition)	Your Memory Have you any concerns about memory loss or forgetfulness? No Additional comments: No problems identified.
Mood	Your Well-Being During the last month have you often been bothered by feeling down, depressed or hopeless? No During the last month have you often been bothered by having little interest or pleasure in doing things? No
Misusing Substances	Staying Healthy Do you smoke tobacco? Yes Occasional smoker Do you think you drink too much alcohol? No

Activities of Daily Living Desired Outcome – Improved Personal Dignity and Autonomy
Dressing / Undressing	Looking After Yourself Can you dress yourself? With help Additional comments: Wife helps with buttons, collars and zips.
Personal Hygiene	Looking After Yourself Can you keep up your personal appearance? Without help Can you wash your hands and face? Without help Can you use the bath or shower? Without help Additional comments: Showers himself with wife supervising. Standing tolerance is limited. Needs grab rails fitted to shower – refer to OT.
Doing Housework / My Daily Tasks	Looking After Yourself Can you do your housework? Unable to do any housework Additional comments: Wife says she does it all.
Eating and Drinking	Looking After Yourself Can you prepare your own meals? Unable to prepare meals Can you feed yourself? Without help Additional comments: Cooking done by wife Staying Healthy Do you have any concerns about your weight or fluid intake No Do you have any special dietary needs? None

Mobility Desired Outcome – Improved Personal Dignity and Autonomy
Mobility in my Home	Looking After Yourself Can you move yourself from bed to chair? Without help Can you get around indoors? With a stick and supervision. Can you manage stairs? No Additional comments: Pushes up from chair arms, finding it hard at the moment. Uses 1 metal stick. Currently only able to manage short distances on the flat.
Mobility outside my Home	Looking After Yourself Can you walk outside? Unable to walk outside Can you go shopping? Unable to do any shopping Do you have any difficulty getting to public services? Yes Additional comments: Had managed to walk to end of drive by end of last Intermediate Care episode - no longer able to at present. Unable use public transport and so can't get to the doctor's surgery.
Falls	Looking After Yourself Have you had any falls in the last six months? Yes Whilst getting out of the shower.

My Care Preferences Desired Outcome - Exercise of Choice and Control
My Care Preferences	{{ Not Covered by Assessment tool }}

Adult Protection Desired Outcome - Freedom from discrimination or harassment
My Sense of Security	Your Safety and Relationships Do you feel safe inside your home? Yes Do you feel safe outside your home? Yes Is there anyone who would be able to help you in case of illness or emergency? Yes
Abuse / Threats	Your Safety and Relationships Do you ever feel threatened or harassed by anyone? No

Equal Treatment Desired Outcome - Freedom from discrimination or harassment
Equal Treatment	Your Safety and Relationships Do you feel discriminated against for any reason? No

My Home Desired Outcome - Improved Quality of Life
My Housing Support Needs	Your Accommodation and Finance Do you have concerns about the cost of your home? Yes Additional comments: Concerned about money, since he had to give up work
My Current housing	Your Accommodation and Finance In general are you happy with your accommodation? Yes Do you have any concerns about the size and space of your home? No Do you have any concerns about the condition of your home? No Do you have any concerns about the location of your home? No
Heating My home in Winter	Your Accommodation and Finance In the last year have you had any difficulty keeping your house warm? No

Keeping Healthy Desired Outcome - Improved Quality of Life
Keeping Healthy	Looking After Your Health Do you take regular exercise? No Has your blood pressure been checked recently? Yes. 140/70 - 13.08.07. 110/70 - 09.08.07. 140/70 - 30.07.07. Do you have a flu jab each winter? Yes Have you had any cancer screening tests in the last three years? No

Being Cared For Desired Outcome - Improved Quality of Life
Being Cared For	{{ Not Covered by Assessment tool }}

Access to Education, Training and Employment Desired Outcome - Making a positive contribution
Access to Education, Training and Employment	Employment, Training and Education Current or previous occupation Warehouseman Are you currently in employment? No Was your disability/ condition/ injury the cause of you giving up work? Yes Additional comments: He would like to get back to work as a warehouseman.

My Social Wellbeing Desired Outcome - Making a positive contribution
My Caring Responsibilities	{{ Not Covered by Assessment tool }}
My Relationships	Your Safety and Relationships Do you receive any help from any family, friends or neighbours? Yes. Friend used to take him out to the pub before this fall Your Well-Being Have you suffered from any recent loss or bereavement? Yes. Father's death of CVA.
Involvement in my Community	Your Well-Being Are you able to pursue leisure interests, hobbies, work and learning activities which are important to you? No Do you feel lonely? Sometimes Additional comments: Used to enjoy going to football matches. Getting back to work is important.
My Religious, Cultural and Spiritual Needs	{{ Not Covered by Assessment tool }}

My Finances Desired Outcome - Economic well-being
My Finances	Your Accommodation and Finance Are you able to manage your money and financial affairs? No Would you like advice about financial allowances or benefits? Yes Do you have any specific legal arrangements? No

Following a recent fall in the shower, Barry was admitted to hospital. This assessment was carried out to inform discharge planning. Barry has reduced mobility and requires assistance with personal care, showering. Barry can't mobilise outside and is socially isolated. His long-term aim is to get back into work.

Detail any physical health risk identified: Poor exercise tolerance What do you consider the level of identified risk to be? Low
Detail any mental health risks you have identified: None What do you consider the level of identified risk to be? None
Detail any risks from others identified: None What do you consider the level of identified risk to be? None
Detail any Activities of Daily Living Risks identified: Toileting, washing and dressing are compromised. What do you consider the level of identified risk to be? Medium
Detail any isolation/access/ environment risks identified: Unable to get out of home at present to maintain social networks. What do you consider the level of identified risk to be? Medium

Referred to community OT team for assessment. Plan to discuss smoking cessation options. Contact Benefits advice team for benefits check and financial assessment