ALL ABOUT ME - The Council for Disabled Children
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Diana Children’s Community Nursing Service ALL ABOUT ME and MY ‘HEALTH ACTION PLAN’ Photo My name is ………………………………………………………………………………………………………………… I was born on ………………………………………………………………………………………………………………… It is hoped that the information contained in this file will help you to communicate with and care for me if my family is not around. 1 Allergies Medicines ………………………………………………………………………………………………………………… Food …………………………………………………………………………………………………………………………. Other……………………………………………………………………………………………………………………….. People who live with me in my home are: ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Other people who are important to me are: …………………………………………………………………………………………………………..……… …..……………………………………………………………………………………………………………… …………………………………………………………………………………………………………..……… …………………………………………………………………………………………………………….……. 2 My School ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………….. My Medicines ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………….. 3 Other People who know me. 1. Name of hospital/centre: ………………………………………………………………………… …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. Consultant/Contact person: ……………………………………………..………………………….. Reason for contact: ………………………………………………………………………… …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. 2. Name of hospital/centre: ………………………………………………………………………… …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. Consultant/Contact person: ……………………………………………..………………………….. Reason for contact: ………………………………………………………………………… …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. 3. Name of hospital/centre: ………………………………………………………………………… …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. Consultant/Contact person: ……………………………………………..………………………….. Reason for contact: ………………………………………………………………………… …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. 4. Name of hospital/centre: ………………………………………………………………………… …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. Consultant/Contact person: ……………………………………………..………………………….. Reason for contact: ………………………………………………………………………… …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. 4 Breathing I have no problems with my chest I have problems with my chest I have nebulisers: The names: …………………………………..…………………………………………………………………………. ……………………………………………………………………………………………………………………………………… The dose / frequency: ………………..…………………………………………………………………………. ……………………………………………………………………………………………………………………………………… I have inhalers: The names: …………………………………..…………………………………………………………………………. ……………………………………………………………………………………………………………………………………… The dose / frequency: ………………..…………………………………………………………………………. ……………………………………………………………………………………………………………………………………… I require suction: Frequently Occasionally Rarely ……………………………………….size suction tube I have a tracheostomy I do not have a tracheostomy Size: ……………………………………………………………. Make: ……………………………………………………………. Changed ? ……………………………………………………………. I need oxygen I don’t need oxygen Details:……………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Other things you need to know: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 5 Communicating with me I usually understand events and experiences I sometimes understand events and experiences I rarely understand events and experiences I usually communicate by using: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… In this way I can tell you: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… If I am in discomfort or pain I: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… If I like something I ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… If I don’t like something I ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Other things I may tell you about are ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 6 Helping me to eat. The way I have my food is by: Mouth Naso gastric tube Gastrostomy tube Size / Make: …………………………………… Size / Make: …………………………………… When I have my food I usually enjoy mealtimes Sometimes enjoy mealtimes Never enjoy mealtimes I particularly like: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… I really dislike: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Positioning (e.g. highchair, pushchair, lap, own chair etc) I can sit unsupported I cannot sit unsupported I can support my own head I cannot support my own head Food texture I like my food: Liquidised Mashed with lumps Mashed without lumps Chopped Other things you need to know ( e.g. type of feed, amount, times, taken with medication? ) ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 7 Drinking I have problems drinking. I do not have problems drinking. I like to drink from: A bottle A cup A beaker Through a straw I like to drink: …………………………………………………………………………………………………….……………………………… …………………………………………………………………………………………………….……………………………… …………………………………………………………………………………………………….……………………………… When I drink I have difficulty sucking When I drink I gulp and often choke When I drink I do not respond when fluid is poured into my mouth The amount of fluid I need each day is ………………………………………………………… Other things you need to know: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 8 Playing and Having Fun Play Activities The Things I Enjoy Doing Most Are…………………………………………………………………….. ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… My favourite toy is: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… My favourite music is: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… My favourite video is: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… My favourite book is: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… A photo of me having fun 9 Helping me to wash and dress When helping me to dress please: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… I am used to having to having a: Bath Shower To have my bath/shower safely I need: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… I like …………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… …………………………………………………………………………………………at my shower/bath time. I have my hair washed: ……………………………………………………………………………………………………………………………………… I like my hair to be: ……………………………………………………………………………………………………………………………………… Please clean my teeth: ……………………………………………………………………………………………………………………………………… My mouth and lips are kept clean by: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Other things you need to know: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 10 Moving Around What I can do on my own: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… The equipment I use to move and get around: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… It is easier to move me by: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………….. In bed to move me, please: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Important things to remember: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… If I go out on trips I need to be kept safe by: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 11 Elimination When I need to go to the toilet I will: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… I wear: Underwear Pad Nappy Other…………………………………………………… I go to the toilet: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… The problems I sometimes always have are: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… The problems I always have are: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… The things I need to help me: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… During the day I: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… During the night I: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 12 How I like to sleep and rest I usually sleep: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… My rest times are: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… My bedtime routine is: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Things I need at sleeptime (that bring me comfort) are: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………. I am most comfortable if: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… I can change my position by myself I cannot change my position by myself. I need help to move: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Other things that will help you look after me: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 13 Understanding me as an individual When caring for me please remember: ï‚· How old I am ï‚· That I like my privacy ï‚· That I often understand more than you think ï‚· I need time to be able to express myself ï‚· How me and my family view life and do not judge Things that make me sad: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… When I am sad I: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… My religion / family beliefs are: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Customs/rituals/ practices you need to know: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 14 The equipment I need so that I don’t hurt myself (e.g. cot sides, helmet, stair gate, fire guard, etc ) are: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… When I am awake: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… When I am asleep: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… When I am indoors: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… When I am outdoors: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Other things you need to know: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 15 What to do if I am poorly Signs when I am poorly: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… When I am poorly I need: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… I need to go to hospital if: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… In an emergency you need to: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Important telephone numbers: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… If I am in pain: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… Things that help are: ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 16 Other health needs (Identified from my Transition Health Self-Assessment) ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 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……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………… 17 Date of 1st assessment Review date Signature of nurse Signature of Parent / guardian completing care plan Providing information. Section reviewed? Signature of nurse 18 Signature of parent/guardian
