Care plan

Care alerts (write in red) For example: allergies, drug reactions, smoker, falls risk, diabetic
Diabetic
Communication
Preferred name: Mr Lewis
Care needs: Visual impairment
Goal: (expected outcome) Effective vision is maintained
Vision / Hearing
Aids / glasses magnifying glasses
Clean and fit glasses daily
Prompt to clean own glasses /

Aids

/ hearing aids ( right left )
Adjust volume daily
Check batteries and clean aids daily
Place objects in range of vision
Read aloud menus/letters/documents
Assist to write
Assist to use telephone / Gain attention before speaking
Speak loudly, clearly and directly
Allow extra time for response
Give step-by-step instructions
Use repetition when difficulty persists
Other / Other
Eye care required Observe for eye discharge / Ear care required
Speech and language / Comprehension issues (For example: inappropriate responses)
Language/s spoken English
Orientate Mr Lewis to time and place
Speech disorder/s
Translate for resident
Take time to listen
Initiate conversation
Use language cards
Use picture cards
Other
Mobility
Care needs: Impaired mobility
Goal: (expected outcome) To maintain safe movement
Ambulation (walking) / Transfers
ambulant (able to walk)
non-ambulant (unable to walk) / independent weight bearing (able to stand)
non-weight bearing (unable to stand)
1-staff assist 2-staff assist
hip replacement knee replacement
amputee ( left right )
Aids / walking stick zimmer frame
wheelchair quad stick
wheeled walker / Aids / bed rail slide sheet gait belt
hoist standing hoist
Hoist sling type and position of loop
Other / Other
Provide direction
Supervise movement
Encourage to maintain mobility
Other
Toileting and continence
Care needs: Urinary incontinence
Goal: (expected outcome) Mr Lewis remain dry at all times
Bladder control / continent incontinent catheter ( occasionally frequently total incontinence )
Bladder management / fluid balance chart toilet (times 0800 1200 1600 2000 )
Other Prefers male care worker with toileting assistance
Bowel control / continent incontinent constipation colostomy ( occasionally frequently total incontinence )
Bowel management / high fibre diet encourage fluid intake aperients bowel chart
Continence aids / Day / Night
Toileting
Toileting aids / commode urinal uridome kylie bed pan
Other Urinal to be used at night
Toileting regime / independent supervise some assistance/prompt fully assist
Adjust clothing Position on toilet Encourage self care Clean perianal area
Other Prefers male care worker to assist with toileting
Showering, dressing and grooming
Care needs: Inability to manage own shower and dressing
Goal: (expected outcome) To maintain optimum hygiene levels
Shower and washing
independent supervise some assistance/prompt fully assist
shower bath spa bath bed sponge flannel wash
Frequency Daily Preferred time 0800
Adjust water temperature Encourage to optimise self care
Other Prefers male care worker for showering assistance
Transfer / walk to shower wheelchair Other
Showering aids / bath trolley shower chair Other
Toiletries / normal soap deodorant aqueous cream moisturiser ( am 8pm )
Other
Hair care / wash in shower wash in bath Preferred days
Dressing and undressing
independent supervise some assistance/prompt fully assist
callipers splints Other
Cultural dressing
Dressing assistance / bra singlet buttons belt zips
stockings socks jewellery make-up shoes
Assist with selecting clothing Other
Grooming
Hair care / independent supervise some assistance/prompt fully assist
Hairdresser
Facial hair wet shave dry shave Frequency Daily
Hair removal Frequency
Nail/foot care / independent supervise some assistance/prompt fully assist
Podiatry visits 6 weekly. Do not cut nails – RN or podiatrist only
Teeth / none some ( upper lower ) all
Cleaning routine Toothbrush and paste: in morning after breakfast, in evening before bed
Dentures / none partial full ( upper lower ) Night in out
Cleaning routine
Pressure area and skin care
Care needs:
Goal: (expected outcome)
Norton Scale / Score [ ] low risk [ ] medium risk [ ] high risk
Pressure relief aids / bed cradle sheepskin cushion bedrail/protectors Other
Pressure area regime / Reposition in bed Reposition in chair Frequency
special mattress (type ) personal chair
Other/specific orders
Skin care / emollient cream to dry skin areas ( daily twice daily ) Preferred time/s 2000
Eating and drinking
Care needs: To maintain blood sugar at optimal levels
Goal: (expected outcome) Blood sugar levels will be within normal range for Mr Lewis
Eating
independent supervise some assistance/prompt fully assist
right-handed left-handed
Preferred place to eat / dining room bedroom Other
Type of diet / normal soft modified soft (minced) puree
Special diet / high fibre diabetic enteral feeding (PEG/NGT)
Special instructions
Aids / modified crockery modified cutlery bowl lipped plate
built up cutlery clothing protector Other
Drinking
independent supervise some assistance/prompt fully assist
right-handed left-handed
Aids / modified cup clothing protector
Thickened fluids / level 1 level 2 level 3
Type of thickener to be used
Sleep and settling routines
Care needs:
Goal: (expected outcome)
Usual time to rise 0700 Usual time to bed 2030 Rest time ( am 1pm )

Preferred sleeping position Pillows required

Sleep Aids / massage music hot packs Other
Room / light on door open door closed bedrail/protectors Other
Night-time patterns
Other preferences (For example: hot drinks or snacks)
Night checks / every hour every 2 hours Other
Specialised care plans
Refer to specialised care plans for / [X] Medications [ ] Pain management [ ] Wound care
[ ] Therapy [ ] Restraint management
Social and human needs/activities
Care needs:
Goal: (expected outcome)
Frequency of visit/contact by family/friends Family visit every weekend. Frequent visits by friends intermittently during the week also.
Religion beliefs/practices Anglican
Pastoral requirements Attends place of worship (attends Anglican service at Fitzroy Falls Aged Care Facility)
Cultural needs
Hobbies/interests Reading, chess, classical music Employment history Retired Bank Manager
Behaviour
Care needs: Episodes of short term memory loss and confusion related to diagnosis of dementia
Goal: (expected outcome) To reduce periods of confusion
Forgets meal times
Orientate Mr Lewis to time and place
Gain attention before speaking
Speak loudly, clearly and directly
Allow extra time for response
Give step-by-step instructions
Use repetition when difficulty persists
Additional comments (For example: special needs, restraint, routines, pain, palliative care, pacemaker)
Terminal care recorded Yes No
Date care plan evaluated (document in progress notes) / Signature
Gwen Burton RN
Fitzroy Falls Aged Care Facility use only
Entered in progress notes Date
Signed Gwen Burton Print name Gwen Burton Position title RN
Review date every 3 months
Document Name: / FORMS - Care Plan - David Lewis / Created Date: / 22-Feb-09
Document No: / Version No: / V1 / Last Modified Date: / 29-Jun-09
© J.N.Bailey Pty Ltd 2009 / Page Sequence: / Page 1 of 1