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ISBAR Mr Y

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IDENTIFY
I
My name is Kirsty and I am the OT working at this facility
It’s my role to ensure residents feel orientated, safe and cared for in their
environment
Mr Y is a 78yo Korean male with presenting early onset Alzheimer’s
dementia.
SITUATION
S
Mr Y has recently transitioned to the long-term care facility three weeks ago. He
presents with worsening confusion, disorientation and wandering behaviours
overnight. Mr Y enters other residents rooms, paces the halls and is often found
awake, wondering outside his bedroom, asking staff repetitive orientation
questions. Mr Y appears distressed over concerns that he is “missing the bus” as
a result of his confusion and dementia symptoms.
Mr Y is not engaging in daytime activities and his wife is concerned about his
engagement and personality changes
BACKGROUND
B
Prior to admission, Mr Y lived with his wife, Mrs Y, running a floristry
business for over 40yrs. Mr Y has a history of OA, frequent UTIs, falls at
home and is supported to take medication to manage these.
Mr and Mrs Y have a son who is supportive, engaged in his father’s care
and was actively involved in encouraging his parents to seek healthcare
providers.
Mr Y was 60yo at onset of symptoms that progressively worsened and
included coordination difficulties, waking overnight and poor memory,
such as forgetting important floral pick-ups. These symptoms
progressively worsened, severely impacting Mrs Ys ability to sustain care
through frequent disturbed sleep, increasing confusion and subsequent
distress. The physical care demands also exceeded what Mrs Y could
provide given declining strength, coordination and increasing falls
With support from community providers, Mr Y was transitioned to the
current facility when it became apparent Mrs Y could not longer manage
Mr Ys care.
ASSESSMENT
A
Mr Y appears to be presenting with sundowning and worsening
confusion overnight. He appears to have difficulties adjusting to the new environment.
He is struggling to conceptualise his wife not being present and has not yet
built relationships with other residents.
Mr Y is extremely fatigued and is therefore unable to stay awake during daytime
hours due to his reversed sleep-wake cycle. He is low of mood.
Mrs Y is also presenting with some emotional challenges both adjusting to the
change in care arrangements and in seeing the changes in her husband
RECOMMENDATION / REQUEST
R
Medical review for overnight medication and sleeping assist
Review by OT for liaison with RN and overnight staff for bedtime routine
and strategies to reduce confusion
Support to Mrs Y regarding the transition, including a clear schedule for
visits and more frequent information updates
OT to support Mr Y to find activities he enjoyed (?related to floristry) to
support engagement and improve moods
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