Mr. Will Smith was born on May 5, 1941 and has been a resident at Mountain

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1 Lena Treadway April 10, 2012 RTH 360- Resident Care Plan Resident Name: Will Smith Background/Demographic Information: Mr. Will Smith was born on May 5, 1941 and has been a resident at Mountain Trace Nursing Home since June 11, He was placed here from a nearby hospital after being diagnosed with chronic renal failure (stage 3-moderate). He is quite the joker, and seems to be a ladies man as well. He enjoys flirting with the women at Mountain Trace, and giving me a hard time about being there. Despite his appearance and participation in most activities at Mountain Trace, Mr. Smith claims to be very depressed the majority of the time and upset with his poor health. Assessments: The assessments I used for Mr. Smith s evaluation were the WHO QOL-BREF and the BANDI-RT. For more information I also used the MDS 3.0 as well as the resident s medical chart. Before starting the WHO QOL-BREF, Mr. Smith seemed to be in a cheery mood, and was coloring in the dinning hall. I asked him if he would mind me asking him a few questions, he told me I better hurry because bingo was starting soon. When I started the

2 assessment he seemed agitated, and kept giving me middle answers as if he didn t care. He then said he wanted to answer all middle answers just to throw them off. After explaining to him that it was for me, and I needed him to be honest, he changed a few answers and started taking it seriously. He did keep getting side tracked during the assessment asking me if I liked his shirt, or if I saw the tree blooming outside. I kept bringing his attention back to the assessment by asking him the next question. When we got to the sex life satisfaction question he took the paper from me and made a box for a 6. I believe he was joking around with me because earlier he was talking about how they have no sex life there. After the assessment he was very happy it was over and said thank God. Mr. Smith scored 9 out of 20 in the physical health domain, 13 out of 20 in the psychological domain, 19 out of 20 in the social relationships domain, and 15 out of 20 in the environment domain. These scores really didn t surprise me; Mr. Smith seems to be very happy in all of these domains except physical health. He appears to be content with his environment, with no cognitive deficits and very socially active, however; it really bothers him that he can not walk, do things on his own, and is in poor health. I believe it would be beneficial for him to have a recreational therapist work with him on his two lowest domains, which were physical health and psychological. The BANDI-RT allowed me to be aware of Mr. Smith s problem areas as well as his strong areas. It helped me get to know Mr. Smith better since he did not speak to me about a lot of things regarding his history, both medical and social. Section two of the BANDI-RT summarizes the resident s cognition, delirium, and mood. Mr. Smith has no cognitive impairments and scored the highest on all categories in this section. He has no

3 behaviors associated with delirium, but as for his mood he scored a 1 out of 30. With his diagnosis of depression this does not surprise me. The next section in the BANDI-RT is done as an interview with the resident to determine recreation/leisure history and interests. Mr. Smith stated he enjoyed most creative activities such as crafts, painting, and woodwork. He loved going to concerts when he could and the only television he likes to watch is when bonanza is on. He laughed at me when I asked about home activities, the outdoors, and exercise. He said he is more of an indoor person. He loves being social, reading and doing puzzles. Going on a cruise and scuba diving are two of the things he mentioned when I asked what new things he would like to try. Needs/Problems: Depression Lack of physical activity At risk for pressure ulcers Wheel chair Extensive assistance needed Strengths: Humorous No cognitive problems Friendly/nice Good memory

4 Goals & Objectives: 1. Goal- To increase physical activity Objective: Within 3 weeks Mr. Smith will participate in a chair exercise program three times a week in the mid-morning hours for 30 minutes in order to increase his physical activity/functioning. 2. Goal- To decrease depression Objective: Within 3 weeks Mr. Smith will participate in a wheelchair biking program five times a week for 15 minutes in order to decrease depression. Action Plan for Resident Involvement: 1. Implement and enroll resident in chair exercise program that meets Monday, Wednesday and Friday for 30 minutes each meeting a. Increase physical activity b. Increase physical functioning c. Decrease amount of assistance needed d. Increase quality of life e. Increase mood 2. Implement and enroll resident in a wheelchair biking program that meets five days a week (Monday-Friday) for a total of 1 hour (with 15 minutes of riding time).

5 a. Decrease depression b. Increase socialization 3. Encourage resident to actively and fully participate in both activities 4. Attend both programs April 23, 2012 through May 14, Re-evaluate Mr. Smith after his last sessions on May 14, 2012 (three weeks) Signature: Lena Treadway, RT student Date: April 17, 2012