Grevilleaaged Care Services

/ Name:Dawn Schmidt
D.O.B.28-12-1954
Room:Wattle 195
Medical:Dr Paul

GrevilleaAged Care Services

Low Care Plan

/ INSTRUCTIONS
•Transfer relevant information from resident assessment tools to Care Plan (CP)
•Write in black pen.
•Date and sign each section as completed.
•When CP complete, date and sign completed document.
•Review CP when the resident’s care needs change and/or according to facility protocol.

/ Name:Dawn Schmidt
D.O.B.28-12-1954
Room:Wattle 195
Medical:Dr Paul

1RESIDENT PROFILE

Brief descriptive “snapshot” of resident

Low care 50 year old with Down syndrome who has lived at home until 3 months ago when her mother died.

2ALLERGIES

Nil known

3ALERTS / (eg. Aggressive behaviour, potential for falls)

Recently become withdrawn, depressed, refusing to eat and attend ADLs

Interventions:

Referral to psychiatrist.

4HABITS

Smoking Yes No

Alcohol Yes No

______

5ADVANCED CARE WISHES

Is there an advanced care directive or similar? Yes No

If yes where is copy located?

______

6COMMUNICATION

Hearing

DeafYes No

Partial Profound

Right Left

Uses aidsYes No

Specify Aid ______

Needs help caring for aids: Yes No

Vision

GlassesYesNo

AlwaysReading only

Other Aids:YesNo

Specify Aid ______

Needs help caring for aids: Yes No

Written

Needs help to write Yes No

Speech

Language spoken: English

Difficulty communicating Yes No

Specify:

Communicates well but needs things to be explained in simple terms

Difficulty comprehending Yes No

Specify:

Has cognitive deficit

Uses aids Yes No

Specific Aids required:

Language Board Signing

Magnetic Letters Pen & Paper

Picture Cards Interpreter

Other: ______

Communication Care Need Identified:

Gain attention – quiet environment

Goal:

To ensure Dawn is able to feel comfortable in her surroundings – good two way understanding

Interventions:

Requires prompting in ADL’s

To commence activity

Throughout activity

To complete activity

Activity modeled

Needs Non-Verbal Cues

Use Facial expression and tone of voice to assist with understanding. Watch Dawn’s body language and facial expression

7MOBILITY

Needs Assistance YesNo

How many staff to assist1 2 3

Refer to Mobility Chart located in Primary File and Resident’s Wardrobe

Therapy YesNo

Date / 3/4/05 / Signature: / P Rogers
Review Date: / Signature:
Date / Signature:
Review Date: / Signature:

Grevillea Hostel

Goal/s

To ensure that Dawn gets some activity each day.

Passive Exercises Yes No

Active Exercises Yes No

Active/Assisted Exercises Yes No

Walking Program Yes No

Other: NA

Refer to Physiotherapy Mobilisation Plan in primary file and resident’s wardrobe

Falls

Potential for falls Yes No

Hip protectors to be worn Yes No

Goal:

Refer App: 108a Restrain Order, App: 108b/c Record of Physical Restraint and App: 108d Review of Restraint Order.

Interventions:

8PERSONAL CARE and ROUTINES

Resident’s preferred routine and needs in personal hygiene, nail and oral care.

Shower / daily / 2nd daily / weekly
Spa / daily / 2nd daily / weekly
Trolley / daily / 2nd daily / weekly
Sponge / daily / 2nd daily / weekly
am / pm

Other: (eg soap moisturiser)

Ensure that Dawn has a shower each day

Hair wash: / daily / 2nd daily / weekly + PRN
How many staff to assist1 2 3

Grooming and Dressing

Help with dressing/undressing YesNo

Specify:

Ensure that Dawn changes her clothes on a regular basis.

How many staff to assist1 2 3

Other (eg shaving, makeup hairdressing etc)

Nail Care

Podiatrist required YesNo

R.N./E.N. to attend YesNo

Care need identified:

Dawn can cut her own nails, care worker to check weekly.

Oral/Dental Hygiene

Dentist / public private

Dentist name:______Phone:______

Dental Appointments:

Own teeth / Upper Lower
Denture / Upper Lower
Denture Labelled / Upper Lower
Assistance needed / Yes No

Best time to clean teeth:

Prompt Dawn to clean her teeth after meals.

Alerts:

Forgets to do oral hygiene

Won’t open mouth

Does not understand

Can’t rinse and spit

Bites toothbrush/staff

Aggressive

Constantly grinding and chewing

Head bent forward/face in downward position

Personal Care Goals:

To ensure mouth is kept clean – promote healthy gums.

Interventions in addition to those recorded above.

Nutrition and Hydration

Goal/s

To ensure Dawn is well nourished and hydrated – to assist in reducing current excess in weight.

Diet

Supervise AssitFeedModelling

Modelling

Type of Assistance Required:

Ensure that Dawn is eating each meal. Record and report the results.

N.B.M.Pureed

SoftCut up

Full

Date / 3/4/05 / Signature: / P Rogers
Review Date: / Signature:
Date / Signature:
Review Date: / Signature:

Grevillea Hostel

Meal times, aids and location

Ensure Dawn comes to the dining room for each meal.

Fluids

N.B.M.Nectar/Soup

As desiredYoghurtGel

SuperviseAssistFeed

Modelling

Aids required:

Sleep and Rest

Goal/s:

To ensure adequate rest and relaxation.

Usual retiring time: / 2100 hrs
Initiated by / Resident Staff
Usual time asleep: / 2200 hrs
Usual time awakening: / 0800 hrs

Describe any sleep inducing interventions used, eg warm milk drink, analgesia, relaxation music, massage, and the effect:

Medications related to sleep/rest.

Does the resident currently require sedatives?

YesNo

Assessed rest pattern needs:

Morning Nap: Nilam/pm

Usual duration:

30 min1 hr1.5 hrs2 hrs

Risk alerts during rest/sleep periods:

Refer to App.32 Sleep Assessment

9SKIN CARE NEEDS

Skin Integrity AssessedYes No

App: 174 Skin Integrity Assessment

Dates attended/reviewed. / 1. On Admission
2. ______

Assessment Outcomes

Skin tear /dry skinYesNo

Wound YesNo

Pressure ulcer “at risk”YesNo

Rash “at risk”YesNo

Excoriation “at risk”YesNo

Other: / NA
Goal for skin care: / NA

If yes above, refer to related App: 231 Wound Assessment and Management Chart for this resident

Specify resident’s skin care routine: / NA

10.MEDICATION ADMINISTRATION

Self administrationYes No

Goals:

To ensure medications are taken, as prescribed by GP.

Interventions

Ensure Dawn takes any medications as prescribed.

11HEALTH STATUS MONITORING

Vital signs to be recordedYes No

Please tick relevant observations and indicate frequency

Observation / Freq. / Observation / Freq.
Pulse / Weight / 1/12
Temperature / BMI
Respirations / Urinalysis
BP / Fluid Chart
BGL / Other

12CONTINENCE AND TOILETING

a.Urinary Continence – competent

______

App: NA Continence and Monitoring Assessment

YesNo

Date attended: ______

Review date: ______

Continent of urineYesNo

Goal:

Treatment and Management Plan Summary –

Increase fluid intake

Strategies to improve mobility

Introduce toileting program

Timed/scheduled toileting program

Prompted toileting program

Bladder retraining program

Date / 3/4/05 / Signature: / P Rogers
Review Date: / Signature:
Date / Signature:
Review Date: / Signature:

Grevillea Hostel

Highlight times as per assessed needs (24 hr clock)

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12
13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24

Pelvic floor exercise program

Use of incontinence product/aids (specify below)

Referral medical or nursing specialist

b.Faecal Continence

App: 4 bowel Management, Assessment and

Evaluation attendedYes No

Date attended: 3/5/05 / Review Date: ______

Continent of faecesYes No

ConstipationYes No

Goal:

To increase fluids, diet and mobility to overcome constipation.

Increase fluid intake

Increase exercise/mobility

Increase dietary fibre

Introduce toileting program

Timed/scheduled toileting program

Prompted toileting program

Planned evacuation program

Highlight days and times as per assessed needs

1 / 2 / 3 / 4 / 5 / 6 / 7 / / 9 / 10 / 11 / 12
13 / 14 / 15 / 16 / 17 / 18 / 19 / / 21 / 22 / 23 / 24

Introduce laxative therapy

Evacuation products/aids (specify below)

To have Aperient if bowels not opened after 2 days.

To have Microlax enema if BNO after 3 days.

Referral medical or nursing specialist

Other: May need regular aperients

c.Toileting

Needs assistance with toileting Yes No

Goal/s

Locating toilet

Transport to/from toilet

Getting on and off toilet

Managing toilet paper/wiping

Performing post toilet hygiene

Prompt and instruct step by step

Model desire action

Staff complete entire procedure

Returning to activity/room

Toilet Risk Management strategies:

Supervise in bathroomYesNo

Shower ChairYesNo

Arm railsYesNo

Other: NA

13.TECHNICAL AND/OR COMPLEX NEEDS

Specify in terms of goals and interventions eg pain management, palliative care, tracheostomy, oxygen therapy etc. and strategies.

14.COGNITIVE AND MENTAL HEALTH

a.Cognitive – assessment attended

SMMSE with the / Yes No
MMSE assistance / Yes No
Score: / 1

Goal:

To promote feelings of contentment and security in her environment.

Interventions:

Explain all procedures before commencing; allow time for her to process information. Promote self-esteem by involving Dawn by allowing her to make choices about her self care.

b.Depression – assessment attended

Initial Depression CheckYes No

Non-Verbal Depression ScaleYes No

Score: ______

Yesavage Depression ScaleYes No

Score:48 Needs case conference

Goal:

To reduce feelings of depression to give Dawn a feeling of well-being and contentment.

Interventions:

Encourage family visits. Encourage Dawn to have control over her daily routine.Encourage Dawn to do her own washing and ironing.

Date / 3/4/05 / Signature: / P Rogers
Review Date: / Signature:
Date / Signature:
Review Date: / Signature:

Grevillea Hostel

c.Behavioural – assessment attended

CreightonYes No

Score: 38 (critical)

C.A.S. Behaviour AssessmentYesNo

Specific Behaviour MonitorYes No

D.B.S.R.S.
(Dementia Behaviour Severity Rating Scale) / Yes No

Score: NA

Management Chart in placeYes No

Refer to Management Chart for each behaviour separately eg aggression, verbal disruption etc.

Behaviours identified

Difficult – Resistive to carers

Aggression

Demanding

At risk of absconding

15.INTEREST AND ACTIVITIES

Goals:

Provide meaningful activity to assist in building self-esteem.

Encourage involvement in activities. Prevent Social Isolation.

Interventions

Emotionally Calming eg validation, doll, water, music therapies.

Encourage Dawn to do her own washing, ironing etc

Involve Dawn in social outings and exercise classes

Mental Stimulation/Cognitive eg quizzes newspaper, jigsaw, and cards.

Photos of her family/friends – talk about places they went to.

Self Esteem Building e.g. beauty care, art, craft.

Hair care, daily clothing choice, hairdresser – 2 monthly

Social Group e.g. sing-a-long, Bingo, movies, cards.

Special theme days

Sing-a-long

Plan a supported holiday

Social Individual (one-on-one) e.g. reading, reminiscence, paired board games such as backgammon

Going to movies once a fortnight, encourage Dawn to read weekly magazines as she did with her mother.

Physical/Tactile e.g. hand massage, balloon game, quoites, carpet bowls.

Exercises to music – weekly

16.CULTURAL

Cultural needs identifiedYes No

Goal:

Interventions eg pets, diet, music, special days, numbers or animals of significance, environmental considerations such as bed positioning.

17.SPIRITUAL

Spiritual needs identifiedYes No

Goals

To provide for Dawn’s spiritual needs within her new environment.

Interventions eg preferred services of worship, clergy, prayer times, icons, medals, position of bible/spiritual literature and special days.

Chapel services every Sunday.

Grief and Loss

Goal:

Encourage Dawn to verbalise her feelings of loss.

Interventions eg. enablements of coping such as counselling, company, comforting and time alone

Counselling with psychiatrist and time with family and friends.

18.SOCIAL AND FAMILY

Family visitsYes No

Specify (who frequency, special considerations)

Brother x 2nd weekly

Encourage visits from friends

Carer input, needs and role

Encourage participation in Dawn’s care.

Date / 3/4/05 / Signature: / P Rogers
Review Date: / Signature: