Care plan

Care alerts(write in red) For example: allergies, drug reactions, smoker, falls risk, diabetic
Diabetic
Communication
Preferred name: Mr Lewis
Care needs: Visual impairment
Goal: (expected outcome)Effective vision is maintained
Vision / Hearing
Aids / glasses magnifying glasses
Clean and fit glasses daily
Prompt 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 requiredObserve for eye discharge / Ear care required
Speech and language / Comprehension issues(For example: inappropriate responses)
Language/s spoken English
Orientate Mr Lewis to time and place
Speech disorder/s
Translate for resident
Take time to listen
Initiate conversation
Use language cards
Use picture cards
Other
Mobility
Care needs: Impaired mobility
Goal: (expected outcome) To maintain safe movement
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: Urinary incontinence
Goal: (expected outcome) Mr Lewis remain dry at all times
Continence
Bladder control / continentincontinentcatheter( occasionally frequently total incontinence )
Bladder management / fluid balance charttoilet (times 0800 1200 1600 2000 )
Other Prefers male care worker with toileting assistance
Bowel control / continentincontinent constipationcolostomy( occasionally frequently total incontinence )
Bowel management / high fibre dietencourage fluid intakeaperients bowel chart
Continence aids / Day / Night
Toileting
Toileting aids / commodeurinaluridomekyliebed pan
OtherUrinal to be used at night
Toileting regime / independentsupervisesome assistance/prompt fully assist
Adjust clothingPosition on toiletEncourage self care Clean perianal area
Other Prefers male care worker to assist with toileting
Showering, dressing and grooming
Care needs: Inability to manage own shower and dressing
Goal: (expected outcome) To maintain optimum hygiene levels
Shower and washing
independentsupervisesome assistance/promptfully assist
showerbathspa bathbed spongeflannel wash
Frequency DailyPreferred time 0800
Adjust water temperatureEncourage to optimise self care
Other Prefers male care worker for showering assistance
Transfer / walk to showerwheelchairOther
Showering aids / bath trolleyshower chairOther
Toiletries / normal soapdeodorantaqueous creammoisturiser ( am 8pm )
Other
Hair care / wash in showerwash in bathPreferred days
Dressing and undressing
independentsupervisesome assistance/promptfully assist
callipers splints Other
Cultural dressing
Dressing assistance / bra singletbuttons belt zips
stockingssocksjewellery make-upshoes
Assist with selecting clothingOther
Grooming
Hair care / independentsupervisesome assistance/promptfully assist
Hairdresser
Facial hairwet shavedry shaveFrequency Daily
Hair removal Frequency
Nail/foot care / independentsupervisesome assistance/promptfully assist
Podiatry visits 6 weekly.Do not cut nails – RN or podiatrist only
Teeth / nonesome ( upper lower )all
Cleaning routine Toothbrushand paste: in morning after breakfast, in evening before bed
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 2000
Eating and drinking
Care needs: To maintain blood sugar at optimal levels
Goal: (expected outcome) Blood sugar levels will be within normal range for Mr Lewis
Eating
independentsupervisesome assistance/promptfully assist
right-handedleft-handed
Preferred place to eat / dining roombedroomOther
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 rise 0700Usual time to bed 2030Rest time( am 1pm )

Preferred sleeping position Pillows required

Sleep Aids / massage musichot packs Other
Room / light ondoor opendoor closedbedrail/protectorsOther
Night-time patterns
Other preferences (For example: hot drinks or snacks)
Night checks / every hourevery 2 hoursOther
Specialised care plans
Refer to specialised care plans for / [X] Medications[ ] Pain management[ ] Wound care
[ ] Therapy[ ] Restraint management
Social and human needs/activities
Care needs:
Goal: (expected outcome)
Frequency of visit/contact by family/friends Family visit every weekend. Frequent visits by friends intermittently during the week also.
Religion beliefs/practices Anglican
Pastoral requirements Attends place of worship (attends Anglican service at Grange House)
Cultural needs
Hobbies/interests Reading, chess, classical music Employment history Retired Bank Manager
Behaviour
Care needs: Episodes of short term memory loss and confusion related to diagnosis of dementia
Goal: (expected outcome) To reduce periods of confusion
Forgets meal times
Orientate Mr Lewis to time and place
Gain attention before speaking
Speak loudly, clearly and directly
Allow extra time for response
Give step-by-step instructions
Use repetition when difficulty persists
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
BarbaraThomas RN
Grange House use only
Entered in progress notesDate
Signed Barbara ThomasPrint nameBarbara ThomasPosition titleRN
Review date every 3 months

Grange HouseCare planPage 1 of 4