Patient Name: Mary Shaw

Background/Demographic information:

I learned that my resident, Mary Shaw, used to be an English professor at Western Carolina University and that she loved reading. I later learned from looking in her chart that she was born on April 25, 1931. She is 80 years old and she was born in Rosman, NC and she was admitted to this facility on August 9, 2011. Her primary language is English, and she is currently divorced. I learned that Mary was admitted to this facility after spending time in the hospital recovering from a right CVA. When I met Mary I asked what her hobbies were and what she liked to do. Her response was, “I like to read”, I then asked her what she enjoyed reading and she said, “I like reading anything I can get my hands on”. She also stated that she liked to do word puzzles. The more she talked the more I realized that she loves reminiscing and just talking with someone especially about her small dog that she has. I made a mental note to myself that I could bring in a magazine for her some time. As time progressed and the more and more I visited Mary, I noticed signs of mild depression and possibly some early signs of dementia.

Assessments

The assessments I used for Mary, were WHOQOL-BREF and the BANDI-RT. These assessments helped me gain information from my resident and get to know her a little better, but most importantly it helped me gain the knowledge I needed so I could write goals and objectives for her. The assessment didn’t really help me with analyzing her MDS since portions of her MDS were unavailable. I did learn about Mary’s interests and activities that she enjoys doing.

I first assessed Mary with the WHOQOL-BREF and when I assessed her she was very cooperative and very talkative. I did not ask Mary the question about her sex life. I simply just checked neither satisfied nor dissatisfied. Mary scored 6 out of 20 on the physical domain, 7 out of 20 on the psychological domain, 11 out of 20 on the social relationships domain, and 10 out of 20 on the environment domain. Mary’s response and results to this assessment did not surprise me since she had told me previously that she is not happy with where she is at and that she had been slightly depressed. Mary’s highest score was in the social relationship domain which I was impressed with, even though it was just above the average, I was surprised because she did not used to get out of her room much. So this does show some improvement with her wanting to get involved with her peers.

Since most of Mary’s scores are just under 50%, this shows that she is not happy with her quality of life and that her personal opinion of her quality of life is poor. The results that I got indicate a need for physical improvement and psychological improvement. Recreational Therapy would help improve Mary’s quality of life by getting her more physically active and helping her increase her psychological well being. We could decrease her depression and improve her quality of life because I fully believe as an RT student that if a client can decrease depression, then their quality of life could improve so much because depression can take over an entire person’s attitude and outlook on their future and their ability to get better. So in other words, if we can decrease Mary’s depression, I believe that this would better her psychologically and spiritually to gain motivation to improve her physical health, and then eventually her entire well being.

The BANDI-RT assessment went very well with Mary. Since Mary loves to talk she was very eager to tell me what activities and leisure she liked to participate in. When I began my assessment, I started off by saying, “I want to ask you about things you enjoy doing in your free time or to stay active.” Then I would follow up the question with a category such as creative, entertainment, games, home activities, nature/outdoors, physical activities, social/community, technology, well-being, and new things he/she would like to try. I learned that Mary likes to quilt, shop, read, and reminisce. I also learned that she likes watching soaps on television as well as walk with her dog, bird watching, completing cross word puzzles, and she is interested in starting a book club in the nursing home.

After gaining knowledge about Mary’s interests by verbally asking her, I looked at the rest of the BANDI-RT and was able to pull information from her chart since the sections of the MDS needed for this assessment were unavailable. Part of the BANDI-RT asked about functioning levels and as stated previously Mary’s chart says that cognitively she is constant however she does have physical impairments. She has no visual, hearing, or speech impairments.

The last part of the BANDI-RT is treatment considerations for my client followed by a care plan. Treatment considerations for Mary include physical psychological, social, and functional. The areas of highest concerns are physical and psychological because of depression and physical impairments and her decreased physical activity. Like I stated earlier, I do believe that once we can increase her physical activity then we could decrease her depression which then can improve her quality of life and her overall well being.

The WHOQOL-BREF and the BANDI-RT indicates a need for recreational therapy for Mary. Not only did both of these assessments provide helpful and useful knowledge for treatment of my client, but they also were extremely easy and simple to administer. These assessments provided me with good medical information along with her chart since the MDS was not available for me to look at.

Strengths:

From the assessments that were given to Mary, I picked up on her strengths. However, I learned about most of her strengths by talking to her and spending time with her one on one. Mary loves to read and she can read anything at all. She can read newspapers, magazines, or books. Mary is also willing to try group activities and becoming more socially interactive. She told me “I know I need to be more social and I am trying. Just the other day I ate lunch in the cafeteria with everyone else instead of in my room by myself.” Mary loves to talk and she loves reminiscing. This is strength because this shows me that she isn’t shy and so when she attends group activities she will be somewhat assertive when beginning a conversation with another resident. I learned that she loved talking on the first day I met her. She opened up and talked to me about all kinds of things on the first day when I met her. Mary is also very good about recalling past events.

  • Can read anything
  • Willing to try socialization
  • Very talkative
  • Can remember past events

Weaknesses:

Some weaknesses I noticed from spending time with Mary and looking through her chart was physical inactivity and her chart stated that she would rather be alone than in a group. She does have limited range of motion but this could be from her stroke as well as left sided weakness. She also does show signs of dementia, even though her chart says she is constant to place/time/ person, she is sometimes confused and will randomly make a statement about something off topic. She also shows signs of depression.

  • Physically inactive
  • Likes to be alone
  • Signs of depression
  • Confused at times

Goals & Objectives:

  1. Goal: Decrease Depression

Objective: After joining the duet biking program, patient will participate in the program under the supervision of a CTRS for 15 minutes a day, 5x a week for 2 weeks.

  1. Goal: Increase physical activity

Objective: Under the supervision of a CTRS, patient will increase physical activity by participating in brain fitness activities such as crossing the midline, crossover with a ball, or pancake clap for at least 30 minutes 5x a week for 2 weeks.

Action Plan:

  1. Enroll Mary in the Duet Biking program at Mountain Trace Nursing Home 5 days a week (Monday – Friday) for 15 minutes per session.
  2. Focus:
  3. Decrease depression
  4. Improve overall mood
  5. Improve sleep patterns
  6. Improve focusing abilities
  7. Increase social skills
  8. Decrease anxiety levels
  9. Engage Mary in Brain Fitness activities at Mountain Trace Nursing Home for 30 minutes each session.
  10. Focus:
  11. Decrease depression
  12. Improve physical activity
  13. Improve range of motion
  14. Increase strength/balance
  15. Increase social skills
  16. Improve sleep patterns
  17. Encourage Mary to try new activities that she may be interested or gain interest in.
  18. Encourage Mary to be more assertive when socializing.
  19. Begin activities on November 28th and go through December 12th.
  20. Re-evaluate in two weeks (December 12th).

Rebecca Smith, RT Student

11/17/2011