ENTEROSTOMAL/WOUND CARE Incontinence

ENTEROSTOMAL/WOUND CARE Incontinence

/ Patient Sticker
INTEGRATED PLAN OF CARE (IPOC)
Admit Date: ____/____/____ Initial Ongoing (Skip pg 1)
Date
Initiated /

FOCUSED NEEDS / PROBLEMS

/ OUTCOME OF ASSESSMENT / COMMUNICATIONS
CASE MANAGEMENT (CM)
Evidence of domestic violence, abuse, homelessness
Assistance with Power of Attorney/ legal issues
Financial issues Psychosocial needs Placement
Receives Home Health Services Home equipment needs
Safety concerns/falls at home Discharge Planning
Other: ______
Currently being followed for: ______/ Services not currently needed See NOTE
Protective Services notified
Info provided (See Pt. Education)
Pt. to be followed
Signature: ______Date: ____/____/____
Evaluation Completed
Signature: ______Date: ____/____/____

ENTEROSTOMAL/WOUND CARE Incontinence

Non healing/open wound Pressure ulcers-all stages
Stoma site / pre op marking New ostomy
Education - Ostomy self care
Other: ______
Currently being followed for: ______/ Services not currently needed See NOTE
Info provided (See Pt. Education)
Pt. to be followed
Signature: ______Date: ____/____/____
Evaluation Completed
Signature: ______Date: ____/____/____
PHYSICAL THERAPY (PT)
New deficits in baseline function with  mobility skills.
Recent fall or fall risk New amputation, THR, TKR
Mobility assessment for post hospital placement
New onset neurological impairment  decline in mobility
Other: ______
Currently being followed for: ______/ Services not currently needed See NOTE
Info provided (See Pt. Education)
Pt. to be followed – Physician order required
Signature: ______Date: ____/____/____
Evaluation Completed
Signature: ______Date: ____/____/____
OCCUPATIONAL THERAPY (OT) New total joints
Decline in self care skills - New Recent
Dx. benefiting from splinting or upper extremity orthotics
Toilet training
Other: ______
Currently being followed for: ______/ Services not currently needed See NOTE
Info provided (See Pt. Education)
Pt. to be followed – Physician order required
Signature: ______Date: ____/____/____
Evaluation Completed
Signature: ______Date: ____/____/____
SPEECH THERAPY (ST) Swallowing or chewing difficulty
Communication difficulty 2º neurological function / trach
Speech: slurred* rambling* aphasia*
S/P surgery of neck, throat, mouth, brain
Post extubation for patient intubated > 7 days
Recurrent pneumonia – especially RLL
Other: ______
Currently being followed for: ______/ Services not currently needed See NOTE
Info provided (See Pt. Education)
Pt. to be followed – Physician order required
Signature: ______Date: ____/____/____
Evaluation Completed
Signature: ______Date: ____/____/____
NUTRITION SERVICES (NS) Enteral/ parenteral feeds
Special diet DKA Chewing difficulty Poor intake > 3 days
Recent unexplained weight loss/gain (>10 lbs in past month)
Non healing wounds/ pressure ulcers
Education – Therapeutic/Special diet Diabetes
Other: ______
Currently being followed for: ______/ Services not currently needed See NOTE
Info provided (See Pt. Education)
Pt. to be followed
Signature: ______Date: ____/____/____
Evaluation Completed
Signature: ______Date: ____/____/____
PHARMACY (P) Use of herbal preparations
Six (6) scheduled prescription or OTC meds
Falls 2º to meds Possible adverse event 2º to meds
Education needed for: ______
Other: ______/ Services not currently needed See NOTE
Pt. to be followed Info provided (See Pt. Education)
Signature: ______Date: ____/____/____
Evaluation Completed
Signature: ______Date: ____/____/____
RESPIRATORY THERAPY (RT)
Smoker Respiratory problems - acute chronic
Oxygen dependent (home O2)
Equipment issues ______
Other: ______
Currently being followed for: ______/ Services not currently needed See NOTE
Smoking Cessation brochure - Offered Declined
Pt. to be followed Info provided (See Pt. Education)
Signature: ______Date: ____/____/____
Evaluation Completed
Signature: ______Date: ____/____/____
SPIRITUAL CARE
Consult Other: ______
Currently being followed for: ______/ Info provided (See Pt. Education) See NOTE
Pt. to be followed
Signature: ______Date: ____/____/____
Evaluation Completed
Signature: ______Date: ____/____/____
ADVANCE HEALTHCARE DIRECTIVES: Assistance requested* In Medical Record Requested* Brought in* - date: ____/____/____
Comments: ______

NCP002A #2 7-6 Page 1

Date Initiated /

SYSTEM PROBLEMS

Check all that apply

/ DESIRED OUTCOME
Check all that apply / Time
Frame / NURSING INTERVENTIONS
Check appropriate interventions
1. PSYCHOSOCIAL
Problems coping with:
Disease process
Communication barriers
Psychosocial / spiritual
Other: ______/ 1.1 Able to express thoughts and feelings
1.2 Able to effectively communicate
1.3 Will verbalize reduction or mgmt. of anxiety
1.4 Advance Healthcare Directives
Brought in Assistance provided
1.5 Other: ______/ Provide emotional support
Involve family/ S.O. in care process
Involve patient in care process
Provide spiritual care/support
Advance Directives follow through
Other: ______
Initials
2. NEUROLOGICAL
Altered mental status
Decreased LOC
Seizure precautions
Other: ______/ 2.1 Patient awake, easily aroused
2.2 Oriented to time, place and person
2.3 Speech clear. Mood, affect, behavior
appropriate to situation
2.4 Other: ______/ Assess for orientation, LOC
Assess neurological deficits
Maintain seizure precautions & monitor for seizure
activity
Other: ______
Initials
3. MUSCULOSKELETAL
Alteration in ability to ambulate,
turn from side to side or actively
move extremities.
Other: ______/ 3.1 Will maintain or improve pre hospital mobility
status
3.2 Involvement of family/ significant others whenever
possible
3.3 Other: ______/ Assist with ADL’s Perform ROM
Assist with toileting Log roll as indicated
Encourage ambulation as tolerated /ordered
Maintain proper body alignment
Involve family in care
Initials
4. GI / GU
Alteration in bowel or bladder
function
Other: ______/ 4.1 Voiding and bowel movements as per pt. norm
4.2 No signs or symptoms of distress
4.3 Other: ______
4.4 Other: ______/ Place NG tube/ monitor output
Assess bowel sounds
Assess for gastric / urinary distention
Monitor I and O, record BM’s
Provide daily foley care
Initials
5. NUTRITION
Alteration in nutrition status
Alteration in fluid and electrolyte
balance
Other: ______/ 5.1 Provide adequate nutrition
5.2 No significant weight loss
5.3 Control of nausea and vomiting
5.4 Other: ______/ Up to chair for meals
Encourage adequate diet fluid intake
Advance diet as tolerated
Offer nutritional supplements
 HOB 30º for enteral tube feeding
Initials
6. ENDOCRINE
Diabetes - Serial CBG’s
Thyroid disturbance
Other: ______/ 6.1 Maintain optimal blood glucose levels
6.2 Other: ______
6.3 Other: ______/ Monitor CBG’s as ordered
Assess for S & S of hypo / hyper glycemia
Other: ______
Initials
7. RESPIRATORY
Difficulty breathing
Shortness of breath
Airway obstruction
Inadeq. oxygenation / ischemia
Other: ______/ 7.1 Will report  in respiratory symptoms
7.2 Will experience ease of respirations and signs of
adequate oxygenation and circulation.
7.3 Other: ______
7.4 Other: ______/ Assess breath sounds
Monitor SpO2 O2 as ordered & wean as tol.
Nebulizer as ordered HOB  at 30º - 45º
TCDB Encourage use of IS
Position for optimal gas exchange
Other: ______
Initials
8.CARDIOVASCULAR
Alteration related to diagnosis
or disease process
CHF Chest pain
Other: ______/ 8.1 Feel free of chest pain
8.2 BP within acceptable parameters
8.3 Reduced peripheral edema
8.4 Pre hospital CV status maintained or improved
8.5 Other: ______/ Monitor BP, HR, pulses, cap refill
Assess heart sounds
Monitor daily weights
Monitor cardiac rhythm
Antiembolic hose / SCD as ordered
Initials
9. PAIN AND COMFORT
Pain related to:
Diagnoses / Disease process
Surgery/ Procedure
Chronic condition
Other: ______/ 9.1 Verbalize acceptable level of comfort/ pain
9.2 Exhibit reduction of indicators of pain
9.3 Other: ______
9.4 Other: ______/ Assess pain with every encounter
Provide appropriate interventions (meds,
alternative modalities) based upon pain
assessment & response to interventions
Reassess pain after every intervention
Initials
10. SKIN INTEGRITY
Impairment:
Actual Potential
Braden Score: ______
Other: ______/ 10.1 Skin integrity will be maintained / protected /
improved
10.2 Free from infection
10.3 Other: ______
10.4 Other: ______/ Turn q 2 hrs.
Protect bony prominences
Assess skin for breakdown – Braden Scale
Check for incontinence, change linens prn
Assess need for specialty bed / mattress
Initials
11. PATIENT SAFETY
Potential for injury
FALL RISK
RESTRAINTS
Other: ______
______/ 11.1 No injury during stay
11.2 Patient receives appropriate care
11.3 Restraint free / Restraints removed ASAP
11.4 Other: ______
11.5 Other: ______/ ID, Allergy, Resuscitation Status bands on pt.
Check at every encounter.
Critical alarms on
Fall Risk Caution / Alert Level interventions
implemented per protocol.
Bed Monitor / Alarms on
Initials

Documentation by- (Signature/Title): ______Date: ____/____/____ Time: ______

______Date: ____/____/____ Time: ______

Completed/ Reviewed by: ______RN Date: ____/____/____ Time: ______

NCP002A #2 7-6 Page 2

PROBLEM PROGRESS EVALUATION

KEY: R = Resolved P = Progressing U = Unresolved

Date: ____/____/____

/ Date: ____/____/____ / Date: ____/____/____ / Date: ____/____/____
DAY / NIGHT / DAY / NIGHT / DAY / NIGHT / DAY / NIGHT
OUTCOME #
GOAL PROGRESS: /
R P U
/ R P U / R P U / R P U / R P U / R P U / R P U / R P U
Comments if not resolved
OUTCOME #
GOAL PROGRESS: / R P U / R P U / R P U / R P U / R P U / R P U / R P U / R P U
Comments if not resolved
OUTCOME #
GOAL PROGRESS: / R P U / R P U / R P U / R P U / R P U / R P U / R P U / R P U
Comments if not resolved
OUTCOME #
GOAL PROGRESS: / R P U / R P U / R P U / R P U / R P U / R P U / R P U / R P U
Comments if not resolved
OUTCOME #
GOAL PROGRESS: / R P U / R P U / R P U / R P U / R P U / R P U / R P U / R P U
Comments if not resolved
CAREGIVER
Initials

CAREGIVER ID

Signature / Title / Initials / Signature / Title / Initials / Signature / Title / Initials

NCP002A #2 7-6 Page 3

PATIENT AND FAMILY EDUCATION *Any changes are to be documented in the MULTIDISCIPLINARY NOTES below

LEARNING SUMMARY – date: ____/____/___ Initials: ______Must be completed within 24 hours of admission.
Readiness to Learn: Willing/able to learn Barriers to learning present: ______
Learners: Patient Family / significant other Caretaker
Learning Preference/ method (LM): None stated VD = Verbal/discussion W = Written materials
Learning Evaluation (LE): S = Satisfactory knowledge, learning and/or competence NR = Needs reinforcement
Document as applicable to diagnosis, learning needs and patient availability
TOPIC / Date: ____/____/____ / Date: ____/____/____ / Date: ____/____/____ / Date: ____/____/____
DAY / NIGHT / DAY / NIGHT / DAY / NIGHT / DAY / NIGHT
LM / LE / LM / LE / LM / LE / LM / LE / LM / LE / LM / LE / LE / LE / LM / LE
Diagnosis, signs and symptoms
Treatment Plan
Prevention / Risk factors
Medication Safety
Pain Management
Activity / Safety
Fall Prevention
Self Care
Diet
Hydration
Habilitation/Rehabilitation
Medical Equipment Use & Safety
Smoking Cessation
EDUCATOR Initials

MULTIDISCIPLINARY NOTES

Date/ Time / DISCIPLINE / NOTES

NCP002A #2 7-6 Page 4

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