Care Plan

Care alerts(write in red) For example: allergies, drug reactions, smoker, falls risk, diabetic
Falls risk
Communication
Preferred name: Jessie
Care needs:visual impairment
Goal: (expected outcome)
Vision / Hearing
Aids / glasses magnifying glasses
Clean and fit glasses daily
Able 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 / Ear care required
Speech and language / Comprehension issues(For example: inappropriate responses)
Language/s spoken English
Responds inappropriately when angry
Speech disorder/s
Translate for resident
Take time to listen
Initiate conversation
Use language cards
Use picture cards
Other
Mobility
Care needs: Unsteady gait related to previous alcohol abuse
Goal: (expected outcome) Mobility will be safely maintained
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 stickzimmer frame
wheelchairquad stick
wheeled walker / Aids / bed railslide sheetgait belt
hoiststanding hoist
Hoist sling type and position of loop
Other / Other
Provide direction
Supervise movement
Encourage to maintain mobility
Other
Toileting and continence
Care needs:
Goal: (expected outcome)
Continence
Bladder control / continentincontinentcatheter( occasionally frequently total incontinence )
Bladder management / fluid balance charttoilet (times)
Other
Bowel control / continentincontinentconstipationcolostomy( occasionally frequently total incontinence )
Bowel management / high fibre dietencourage fluid intakeaperients bowel chart
Continence aids / Day / Night
Toileting
Toileting aids / commodeurinaluridomekyliebed pan
Other
Toileting regime / independentsupervisesome assistance/prompt fully assist
Adjust clothingPosition on toiletEncourage self care Clean perianal area
Other
Showering, dressing and grooming
Care needs:
Goal: (expected outcome)
Shower and washing
independentsupervisesome assistance/promptfully assist
showerbathspa bathbed spongeflannel wash
FrequencyPreferred time
Adjust water temperatureEncourage to optimise self care
Other
Transfer / walk to showerwheelchairOther
Showering aids / bath trolleyshower chairOther
Toiletries / normal soapdeodorantaqueous creammoisturiser ( am pm )
Other
Hair care / wash in showerwash in bathPreferred daysSunday & Wednesday
Dressing and undressing
independentsupervisesome assistance/promptfully assist
callipers splints Other
Cultural dressing
Dressing assistance / bra singlet buttons belt zips
stockingssocksjewellerymake-upshoes
Assist with selecting clothingOther
Grooming
Hair care / independentsupervisesome assistance/promptfully assist
Hairdresser
Facial hairwet shavedry shaveFrequency
Hair removal Frequency weekly
Nail/foot care / independentsupervisesome assistance/promptfully assist
Podiatry visits monthly
Teeth / nonesome ( upper lower )all
Cleaning routine
Dentures / nonepartialfull( upper lower ) Night inout
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 cradlesheepskincushionbedrail/protectorsOther
Pressure area regime / Reposition in bedReposition in chairFrequency
special mattress (type )personal chair
Other/specific orders
Skin care / emollient cream to dry skin areas ( daily twice daily )Preferred time/s
Eating and drinking
Care needs:
Goal: (expected outcome)
Eating
independentsupervisesome assistance/promptfully assist
right-handedleft-handed
Preferred place to eat / dining roombedroomOther on verandah
Type of diet / normalsoftmodified soft (minced)puree
Special diet / high fibrediabeticenteral feeding (PEG/NGT)
Special instructions
Aids / modified crockerymodified cutlerybowllipped plate
built up cutleryclothing protectorOther
Drinking
independent supervisesome assistance/promptfully assist
right-handed left-handed
Aids / modified cupclothing protector
Thickened fluids / level 1level 2level 3
Type of thickener to be used
Sleep and settling routines
Care needs:
Goal: (expected outcome)
Usual time to rise0600Usual time to bed 2200Rest time( am pm )

Preferred sleeping position Back Pillows required 2

Sleep Aids / massage musichot packs Other
Room / light ondoor opendoor closedbedrail/protectorsOther
Night-time patterns / Wakes up frequently
Other preferences (For example: hot drinks or snacks) / Hot milk with 2 teaspoons of sugar
Night checks / every hourevery 2 hours Other
Specialised care plans
Refer to specialised care plans for / [ X ] Medications[ ] Pain management[ ] Wound care
[ X ] Therapy[ ] Restraint management
Social and human needs/activities
Care needs:
Goal: (expected outcome)
Frequency of visit/contact by family/friends Has a close friend, Mary Black, who visits monthly
Religion beliefs/practices R.C.
Pastoral requirements Priest to visit Attends place of worship (day/s Saturdays )
Cultural needs
Hobbies/interests Knitting, drawing and painting Employment history Barmaid for 30 years
Behaviour
Care needs: Periods of aggressive behaviour
Goal: (expected outcome) Maintain safety and comfort during outbursts of aggression
Encourage Jessie to got to her room when she displays aggressive behaviour
Additional comments (For example: special needs, restraint, routines, pain, palliative care, pacemaker)
Terminal care recorded YesNo
Date care plan evaluated (document in progress notes) / Signature
Barbara Thomas RN
Grange House use only
Entered in progress notesDate
Signed Barbara Thomas RNPrint nameBarbara ThomasPosition title RN
Review date every 3 months

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