Care plan

Care alerts(write in red) For example: allergies, drug reactions, smoker, falls risk, diabetic
Communication
Preferred name: May
Care needs:
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 -
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
Speech disorder/s
Translate for resident
Take time to listen
Initiate conversation
Use language cards
Use picture cards
Other
Mobility
Care needs:
Goal: (expected outcome)
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: Potential for skin breakdown due to incontinence
Goal: (expected outcome) To maintain good skin integrity
Continence
Bladder control / continentincontinentcatheter( occasionally frequently total incontinence )
Bladder management / Toilet (times 0600 1000 1400 1600 2000 )
Other
Bowel control / continent incontinent constipation colostomy ( occasionally frequently total incontinence )
Bowel management / high fibre dietencourage fluid intake aperients bowel chart
Continence aids / Day medium pad / Night overnight pad
Toileting
Toileting aids / Commode at nighturinaluridomekyliebed pan
over-toilet frame Other
Toileting regime / independentsupervisesome assistance/promptfully assist
Adjust clothingPosition on toiletEncourage self care Clean perianal area
Other
Showering, dressing and grooming
Care needs: Potential for infections related to incontinence
Goal: (expected outcome) To maintain optimal personal hygiene
Shower and washing
independentsupervisesome assistance/promptfully assist
showerbathbed spongeflannel wash
FrequencyPreferred time
Adjust water temperatureEncourage to optimise self care
Other
Transfer / walk to showerwheelchairOther
Showering aids / shower chairOther
Toiletries / normal soapdeodorantaqueous creammoisturiser ( am pm )
Other
Hair care / wash in showerwash in bathPreferred days Fridays
Grooming
Hair care / independentsupervisesome assistance/promptfully assist
Hairdresser
Facial hairwet shavedry shaveFrequency
Hair removal Frequency
Nail/foot care / independentsupervisesome assistance/promptfully assist
Podiatry visits
Teeth / nonesome ( upper lower )all
Cleaning routine
Dentures / nonepartialfull( upper lower )Nightinout
Cleaning routine
Dressing and undressing
independentsupervisesome assistance/promptfully assist
calliperssplintsOther
Cultural dressing
Dressing assistance / bra singlet buttonsbeltzips
stockingssocksjewellery make-upshoes
Assist with selecting clothingOther
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/smorning
Eating and drinking
Care needs:
Goal: (expected outcome)
Eating
independentsupervisesome assistance/promptfully assist
right-handedleft-handed
Preferred place to eat / dining roombedroomOther Lounge room in armchair with tray on lap
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
independentsupervisesome assistance/promptfully assist
right-handedleft-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 rise 0600Usual time to bed 2130Rest time( am 2 pm )

Preferred sleeping positionPillows required

Sleep Aids / massage musichot packsOther
Room / light ondoor opendoor closedbedrail/protectorsOther
Night-time patterns / Leaves bathroom light on. Sometimes wakes in the night and reads.
Other preferences (For example: hot drinks or snacks)
Night checks / every hourevery 2 hours Other
Medications

Current medications

/

eye dropsear dropsOther

independentsupervisesome assistance/promptfully assist
pre-packedmeasureself-administer

Blood sugar level testing

/ independentsupervisesome assistance/promptfully assist

Frequency

Specialised care plans
Refer to specialised care plans for / [ x]Medications
[ ]Pain management[ ]Wound care
[ x]Therapy[ ]Restraint management
OHS
Completed injury risk assessment forms / Home environmentYesNo
Client assessmentYesNo
Social and human needs/activities
Care needs: Potential for social isolation
Goal: (expected outcome) To ensure Sybil has opportunity to develop and maintain social networks
Frequency of visit/contact by family/friends Monthly visits by daughter and son-in-law. Has close friendship with neighbour who checks on Sybil daily.
Religion beliefs/practices Lutheran
Pastoral requirementsAttends place of worship (day/s Sundays – picked up and taken to Church by parishioners. )
Cultural needs
Hobbies/interests Embroidery, Photography, ArtEmployment history Retired secretary
PetsName/s MarmaladeType/s Ginger Cat
client manages petrequires prompt and assistance in pet carefully assist pet care
Socialgroup/s Bridge club – Wednesday afternoons picked up by friends
Preferred activity/games Bridge
Community care social outings(Frequency Once weekly )
Requirements
Taxi vouchersYesNo
Domestic needs/activities
independentsupervisesome assistance/promptfully assist
Frequency ( dailyevery 2nd dayweeklyfortnightlyOther )
Requirements / Shopping
Washing clothes
Cleaning
Cooking
Transport required for appointments and outings
Gardening – Lawn mowing and edges fortnightly, weeding/pruning assistance monthly

Other

Emotional support
Recently widowed, requires time spent to listen and support. Husband name Jim, died last month from sudden heart attack.
Behaviour
Care needs:
Goal: (expected outcome)
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
Grange Community Care use only
Entered in progress notesDate
Signed Tanya TomlinsonPrint nameTanya TomlinsonPosition titleCare Manager
Review date every 3 months

Grange Home CareCare planPage 1 of 5