CARE PLAN
GOALS AND ACTIONS
ANOREXIA
Goal:
- Make dietary changes for long term health.
- Achieve optimal physical and mental wellbeing.
Action:
- Ongoing monitoring/review of diet.
- Counselling, support and disease management.
- Monitor haematology and blood pressure.
ALZHEIMER’S DISEASE
Goal:
- Achieve optimal physical and mental wellbeing
Action:
- Regular physical and stimulating leisure activities.
- Medications as prescribed.
- Counselling and support.
- Contact with Alzheimer’s Association of Victoria for information and support services. Contact with Occupational Therapist for assistance regarding home aids etc.
Monitor:
- Observe clinical features
- Review of self management
ASTHMA
Goal:
- Confirm diagnosis
- Action – spirometry
- Assessment of symptom control
- Action – reviews of 2 week diary of symptoms and peak flows.
- Manage medications to achieve best lung function
- Action – Review asthma medication and technique of puffers
- To identify and minimize environmental triggers and allergens
- Action – Skin prick allergy testing
Medication
Management
Goal
- Prevention and relief of symptoms, patient education
Action
- Regular assessments and ensure patient understanding. Regular prescriptions.
Education
Goal
- To promote better self-management of asthma through greater understanding of the disease.
- Action – asthma education addressing: cause of asthma, social and lifestyle factors, triggers and avoidance, inhaler techniques, emergency action plan, differentiate reliever and preventer medication (Provider responsible is GP and Asthma Educator)
Goal
Action
- Patient to self-administer and understand the effects of medications
- Differentiate reliever and prevention medication
- Teach and review device technique/care
Specialist
Assessment
Goal
- To identify changes in medical condition and change treatment accordingly
Action
- To assess annually (Provider responsible is respiratory specialist)
Goals of Patient – keep a 2 week diary of symptoms and peak flows
-learn about asthma and triggers
-how to recognize deterioration
-understand what actions to take when asthma worsens
-learn about asthma medications and delivery systems
-regular review with GP when free of acute exacerbations
-early appointment with GP for treatment of exacerbations
BLADDER
INCONTINENCE
Goal
- To achieve and manage adequate bladder control/bowel pattern
Action
- Encourage 9x drinks per day
- Limit drinks 2 hours pre bed time
- Pelvic Muscle exercises
- Continence pads/aids
STRESS INCONTINENCE
Goal
- To maximize urinary continence, provision of comfort
Action
- Education re pelvic floor exercises, provision of continence aids, possible referral to Women’s Physio Practice
URETHRAL STRICTURE
Goal
- To maintain optimal urine flow
Action
- Regular review with urologist regarding internal urethrotomy and need for dilatations
URINARY TRACT INFECTION
Goal
- Prevent recurring infection
Action
- Adequate fluid intake, education onUTI prevention
- Medication as required
VOIDING DIFFICULTIES
Goal
- To ensure urine flow rate returns to optimal level
Action
- Review with urologist for repeat flow rate and bladder scan
BOWEL
COELIAC DISEASE
Goal (Dietary)
- Make dietary changes for long-term health
Action
- Gluten free diet. Reduce fat, increase fibre and spread carbohydrates throughout the day. Regular exercise
COLOSTOMY – AP RESECTION
Goal
- Regain improved function in and perform activities of daily living with minimal or no restrictions
- Management of colostomy
Action
- Assess social circumstances, home environment and nursing needs to provide short-term interventions in order to remain living at home
- Decrease the risk of future admissions to hospital
IRRITABLE BOWEL
Goal
- To achieve/manage an adequate bowel pattern. To identify and minimize triggers
Action
- Regular reviews with gastroenterologist. Patient to demonstrate an understanding of the condition and its treatment by adhering to a prescribed regime, including diet, exercise and medications
DIVERTICULITIS
Goal
- Regular assessment of bowel condition
- Bowel to be free of inflammation and ? obstruction
Action
- Regular reviews with gastroenterologist when
- When diverticulitis apparent rest at home suggested with diet modification; review with gastroenterologist as required.
CARDIAC
ANGINA
Goal
- Promote self-management through greater understanding of the condition
Action
- If further episodes of chest pain – suggest further testing and review of medications
- Use of nitro lingual spray to relieve angina, monitor effectiveness
- If chest pain not relieved in 10-15min _____ ambulance should be called
- _____ tablets – check expiry date
AORTIC STENOSIS
ATRIAL FIBRILLATION
Goal
- To identify changes in cardiac condition and change treatment accordingly
- Cardiac status to remain well controlled and asymptomatic
- To promote better self management, through greater understanding of the condition
Action
- Regular blood tests, medications reviews and blood pressure monitoring
- Attend yearly reviews
- Monitor cardiac status
- Regular reviews with cardiologist
- Reinforce healthy eating and lifestyle patterns.
- Discourage smoking
HYPERCHOLESTEROLAEMIA
Goal
- Reduce risks associated with hypercholesterolemia
- Improve serum cholesterol profiles, achieve target cholesterol of 4.0
Action
- Regular serum cholesterol profiles, review medications, diet modification
HYPERTENSION
Goal
- Maintain blood pressure within acceptable parameters/maintain stable blood pressure
- Improve blood pressure control
- To control and stabilize blood pressure
- Assess and record blood pressure each visit to assess for hypo/hypertension and monitor the effectiveness of anti-hypertensive therapy
Action
- Regular blood pressure monitoring, review anti-hypertensives
- Annual ECG monitoring
- Six weekly review of blood pressure medications
- Patient education of risk factors
MEDICATIONS
Goal
- Increase knowledge of medications and ensure correct use
- Renewal of scripts and monitor medication compliance
- Monitor medication to maintain general cardio protective therapy
- Cardiovascular prophylaxis
Actions
- Dispense medications as prescribed
- Continued patient education regarding scripts
- Annual medication review to ensure compatibility of medications and assess medication compliance
CANCER
CANCER – BLADDER
Goal
- Early detection (of recurrence)
Action
- Regular Cystoscopy
CANCER – BREAST
Goal
- Early detection and management of changes in breast tissue
Action
- Self examination of breasts monthly; regular clinical breast checks. If lump consult doctor without delay, 2 yearly mammogram due
- Mammogram 2 yearly until 70, and then only on request if last two mammograms clear
CANCER – SKIN
Goal
- Prevention and early detection of skin cancer
- Management and early identifications of skin lesions
Action
- Ongoing surveillance and Sunsmart measures
CANCER – PROSTATE
Goal
- Ongoing surveillance and subsequent treatment of any changes in prostate condition
Action
- Regular review with urologist. Regular PSA levels
PAP SMEAR
Goal
- Early detection and management of changes in cervical tissue
Action
- 2 yearly Pap Smear test until 70, and then not if last two clear
METASTESES
Goal
- Ongoing surveillance and subsequent treatment
Action
- Regular review with specialists and subsequent treatment as required
- Support from co-ordinated team of health professionals
CHOLELITHIASIS
Goal
- To monitor signs and symptoms caused by gallstones
Action
- Regular reviews, if symptoms appear – active therapy may be warranted
CHRONIC FATIGUE
Goal
- Perform activities of daily living with minimal or no restrictions
Action
- Rest combined with programme of exercise, support and counselling
COAD
Goal
- To improve function, condition to remain well controlled
Action
- Avoidance of bronchial irritants, exercise as tolerated, oxygen therapy as required,
medication reviews
DERMATITIS
Goal
- To maintain healthy skin
Action
- Avoid allergens, topical treatment and medication as required
depression
Goal
- Achieve optimal mental well being
- To maintain mood and review need for antidepressant medication. Engage community psychologist.
- Help change poor self esteem
- Psychological support and monitoring of medications for recurrent depression
- Close monitoring of effectiveness of medication ------with GP
Action
- Counselling and support; appointment with psychiatric health professional; review effectiveness of medications
CELLULITIS
Goal
- Early detection and treatment of cellulitis
Action
- Early introduction of antibiotics
- Raised legs whilst sitting
- Dressings to affected areas as ordered
CERVICAL DYSPLASIA
Goal
- Early detection of any cervical changes
Action
- Regular vaginal and vulval coloscopy
DIABETES
Goal:Maintain adequate control of diabetes; To prevent, delay or detect complications of diabetes;
Improved glycaemic control
ActionRegular serum glucose profiles, review hypoglycaemics; Biannual HbA1C test to monitor long term maintenance of diabetes; regular visit to podiatrist, annual diabetic eye review, annual cholesterol check and 3-6/12 outside acceptable parameters.
Modify diet and increase levels of physical activity in order to help with weight and diabetes control.
Monitor renal function – annual 24 hour urine collection, micro albumin, urea and electrolytes
GoalTo increase knowledge of BSL’s and knowledge of diabetes
ActionReview BSL monitoring and keep BSL diary
Dietary
GoalMake dietary changes for long term health. To understand the role of diet and exercise in diabetes management.
ActionAttend diabetes education session which will address: healthy eating and lifestyle for diabetics
EducationTo understand what diabetes is and the type of treatment suited to you.
Goal ActionAttend diabetes education session which will address: what diabetes is, medication and monitoring of blood sugar level in the management of diabetes
Foot Care
GoalMaintain good foot care and attend to any new …………………………. Regard to the feet.
ActionRequires footcare every three months to ensure good foot health and maintain mobility.
GoalTo maintain healthy feet
ProblemDifficulty attending own foot care
ActionTo attend diabetes education session to learn more about healthy foot care and prevention of foot injury, regular visits to podiatrist.
Eyecare
GoalTo avoid eye complications
To prevent diabetic retinopathy
Annual review to assess potential diabetic eye complications
OverweightTo have a diet of low fat and low glycaemic index foods
DIET – IMPROVE
GoalWeight loss; improve serum cholesterol profiles and blood pressure control.
To develop an exercise regime appropriately suited to aid weight loss, increase muscle strength and improve overall wellbeing.
Action:Review of diet, provide information and follow up diet modification.
DIETICIANReferrals to dietician as often as dietician recommends to assist reaching target/s if outside of target range.
EARS
HEARING
GoalTo improve hearing impairment / to improve the clarity of hearing
ActionProvision of hearing aid
Six monthly hearing tests
Regular removal of cerumen an rescreening by audiologist
TINNITUS
GoalTo improve clarity of hearing and relief of tinnitus
ActionRegular hearing ests; ? playing of music, etc. to mask effects of tinnitus
OTITIS EXERNA
GoalTo relief pain in ears and maintain dry and clear ear canals
ActionRegular assessment by GP, ear drops as required, use wax to outer ear whilst swimming
EUSTACIAN TUBE BLOCKAGE
GoalTo relief pain and feeling of blocked ears
ActionRhinocort spray to reduce polyps in Eustacian Tubes and improve patency
EMPHYSEMA
GoalTo maintain oxygen saturation rates at optimal level
ActionRegular reviews with specialist, oxygen therapy (at home 2L/minute etc) as required, regular Hb checks
EPILEPSY
GoalTo remain well controlled
EYES
GoalReduction of thrombo-embolic episodes
Treatment of cataracts
ActionReviews, upgrade of glasses
MACULAR DEGENERATION
GoalAssessment of ongoing visual degeneration and management
ActionOpthamologist review, assistance with daily needs when and if necessary
VISION
GoalMonitor vision status
Monitor refractive status and maintain optimal visual acuity
Monitor IOL implants for stability and posterior capsular thickening
Monitor retinal integrity
Monitor corneal surface integrity for chronic dry eye, eyes to be adequately hydrated
Monitor retinal vasculature for Warfarin toxity
ActionRegular review and awareness of visual deterioration
Annual assessment of eyes to monitor visual acuity and eye disease
Provision of aids to ensure home safety through Vision Foundation Australia
FIBROMYALGIA
GoalRelief and control of pain
Actionmedication as required, exercise, local application of heat and massage as tolerated.
FRACTURES
HIP – Post Surgery
GoalTo maintain optimal joint mobility and express relief of pain
ActionRegular review, physiotherapy and exercise
GASTRIC REFLUX
GoalKeep symptoms under control
To control pain due to reflux
ActionTo modify diet and monitor effectiveness of Nexium
GOUT
GoalTo attain an optimal level of functioning within the physical limitations of gouty arthritis; the patient will demonstrate an understanding of the disease and its treatment goals by adhering to a prescribed regime, including diet, exercise, rest and medications.
GoalTo maintain joint mobility and be pain free.
ActionDiscuss …. GP prescribed regime including diet, exercise, rest and medications.
HAEMOCHROMATOSIS
GoalSerum Ferritin levels to be within acceptable parameters, prevention of liver disease.
ActionRegular review with haematologist, regular venesections inrelation to serumferritin levels.
HEPATITIS C
GoalTo achieve optimal physical well being, to prevent any transmission of Heptatitis C.
ActionOngoing monitoring; counselling and support; care should be taken in areas where transmission of Hepatitis C through blood may occur.
HERPES – GENITAL
GoalSymptomatic treatment of sores; to prevent any further transmission of Genital Herpes.
ActionKeep sores dry and clean, salt baths, rest, analgesia, cotton underwear; prevention of transmission by use of condoms and avoid sexual contact if sores present.
HODGKIN’S DISEASE
GoalArrest disease, maintain quality of life for as long as possible.
ActionRegular review of medications and blood tests.
MEMORY LOSS / CONFUSION
GoalImprove mental state
Improve memory loss
ActionMaintain and closely observe therapeutic dose of medication
Need for health assessment
MIGRAINE
GoalTo assist in preventing migraine headaches by reducing probable stimuli, relief and control of pain.
ActionEducation and provision of appropriate medication.
MULTIPLE SCLEROSIS
GoalTo reduce frequency of neurologic exacerbations. Perform activities of daily living with minimal or no restrictions.
ActionRequires visit to neurologist, ongoing monitoring of medication. Maintain as normal and active a life as possible, avoiding over work and fatigue.
GUIDELINES FOR GPS CARING FOR PATIENTS WITH LYMPHOEDEMA
Goals of Treatment:
- Minimise swelling.
- Rduce risk of complications (especially cellulitis) and reduce long term changes due to limb lymphoedema (skin and joint changes).
- Minimise psychological impact.
Actions:
- Encourage self-management activities – skin care, self massage and exercise.
- Avoid affected limb for injections and blood pressure readings.
- Check garments (if required) are replaced 4-6 monthly.
- Check that there is annual (as a minimum) review by a qualified therapist.
- Treat episodes of cellulitis at an early stage, to prevent further damage to the lymphatic vessels, and further exacerbation of the swelling. Consider long term antibiotics for recurrent cellulitis.
For lower limb:
- Treat tinea aggressively to reduce the risk of episodes of cellulitis.
- Arrange podiatry if necessary.
All patients:
- Encourage weight towards the healthy range.
- Encourage regular activity.
- Monitor psychological wellbeing. Suggest support group.
Travel care:
- Refer to therapist for advice regarding garments for long car journeys and flights over 3-4 hours.
- Consider supply of antibiotics if significant risk of cellulitis.
OESOPHAGEAL REFLUX
GoalControl of reflux
ActionReview symptoms and monitor effectiveness of medications.
OSTEOARTHRITIS
GoalTo maintain optimal joint mobility and express relief or control of pain.
ActionAssess level of discomfort; monitor side effects of anti-inflamatory agents and analgesics.
OSTEOPOROSIS
GoalRelief and control of pain
Maintain bone mineral density
ActionAppropriate medication and physiotherapy
Maintain physical activity to prevent atrophy and further bone deterioration / destruction.
Fosamax each Sunday
Walking as weight bearing exercise.
PAIN
PHYSIO
GoalRegain improved function in ……… and perform activities of daily living with minimal or no restrictions.
BACK PAIN
GoalRelief and control of pain
ActionAppropriate medication and physiotherapy.
LEG PAIN / FALLS / LOSS OF BALANCE
GoalTo maintain optimal joint strength, control and mobility and express the relief or control of pain.
ActionReinforcement of fall and balance programme. Ongoing monitoring of medications. Continue with home exercise programme.
Therapeutic exercise programme.
Graduated exercise rehabilitation programme.
Assess functional tolerance and physical capacity.
Engage in a physically directed rehabilitation programme.
Exercise programme under supervision of physio.
Programme designed to meet Mrs….. needs
NECK
GoalRelief and control of pain; return to normal functioning ability
ActionMedication as required, engage in rehabilitation programme as directed by specialist / physiotherapist.
SHOULDER
GoalRelief and control of pain. Attain and maintain optimal functioning ability.
PARKINSON’S DISEASE
GoalReduce neurological deficits associated with Parkinson’s Disease.
ActionMonitoring of medication
PERIPHERAL NEUROPATHY
GoalTo maintain optimal mobility
ActionRegular review with neurologist, medication and treatment as prescribed.
PERIPHERAL VASCULAR DISEASE
GoalTo improve vascular function and prevention of complications.
ActionOrder for compression bandage / stocking, regular assessment.
PODIATRIST
GoalProvide footcare and education relating to maintaining healthy feet.
To attain an optimal level of functioning.
Maintain good footcare and attend to changes/deterioration.
ActionAnnual review of feet, assessing for foot complications.
Annual review to three monthly review of feet
General care of feet and maintenance of orthotic therapy as required.
Required footcare every three months to ensure good foot health and maintain mobility.
Two monthly care – general treatment – keep feet healthy, free of injury and optimising his / her mobility.
POLYCYTHAEMIA
GoalCondition to remain well controlled.
ActionRegular blood tests and treatment as indicated by test results.
PSORIASIS
GoalTo improve skin health and prevent any complications.
To control psoriasis
ActionEducate patient re skin care and apply appropriate skin preparations.