Care plan

Care alerts(write in red) For example: allergies, drug reactions, smoker, falls risk, diabetic
Falls Risk
Communication
Preferred name: Ethel
Care needs: Partially vision impaired
Goal: (expected outcome) To maintain visual accuracy
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 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 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: Right sided muscle weakness (hemi-plegia) related to stroke (Cerebro Vascular Accident)
Goal: (expected outcome) To maintain usual daily activities
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:
Goal: (expected outcome)
Continence
Bladder control / continentincontinentcatheter( occasionally frequently total incontinence )
Bladder management / fluid balance charttoilet (times)
Other
Bowel control / continentincontinentconstipationcolostomy( occasionally frequently total incontinence )
Bowel management / high fibre dietencourage fluid intakeaperientsbowel chart
Continence aids / Day / Night
Toileting
Toileting aids / Commode at nighturinaluridomekyliebed pan
Other
Toileting regime / independentsupervisesome assistance/prompt fully assist
Adjust clothingPosition on toiletEncourage self care Clean perianal area
Other
Showering, dressing and grooming
Care needs: Inability to shower, dress and groom self
Goal: (expected outcome) To maintain high level of personal hygiene and personal presentation
Shower and washing
independentsupervisesome assistance/promptfully assist
showerbathspa bathbed spongeflannel wash
Frequency DailyPreferred time 0900
Adjust water temperatureEncourage to optimise self care
Other Assist with washing left side of body, back and legs
Transfer / walk to showerwheelchairOther With quad stick
Showering aids / bath trolleyshower chairOther
Toiletries / normal soapdeodorantaqueous creammoisturiser ( am 2100pm )
Other
Hair care / wash in showerwash in bathPreferred days Tuesday and Friday
Dressing and undressing
independentsupervisesome assistance/promptfully assist
callipers splints Other Assist with dressing right side of body
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
Hair removal Hair removal creamFrequency Fortnightly
Nail/foot care / independentsupervisesome assistance/promptfully assist
Podiatry visits
Teeth / nonesome ( upper lower )all
Cleaning routine
Dentures / nonepartialfull( upper lower ) Night inout
Cleaning routine Brush and soak in denture cleaning solution
Pressure area and skin care
Care needs: Potential for skin break-down
Goal: (expected outcome) For skin to remain healthy and intact
Norton Scale / Score[ x ] low risk[ ] medium risk[ ] high risk
Pressure relief aids / bed cradlesheepskincushionbedrail/protectorsOther
Pressure area regime / Reposition in bedReposition in chairFrequency Twice during nightshift
special mattress (type )personal chair
Other/specific orders
Skin care / emollient cream to dry skin areas ( daily twice daily )Preferred time/s 2100
Eating and drinking
Care needs:
Goal: (expected outcome)
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 0800Usual time to bed 2100Rest time( am 1300 pm )

Preferred sleeping position On back with pillow under right side Pillows required 2 + 1 triangle

Sleep Aids / massage musichot packs Other
Room / light ondoor opendoor closedbedrail/protectorsOther
Night-time patterns / Ensure TV is in correct position and remote and call bell by left hand
Other preferences (For example: hot drinks or snacks) / Put lolly container and tissues on left bedside table where Ethel can reach them
Night checks / every hourevery 2 hours Other Check twice to reposition 2330 and 0500
Specialised care plans
Refer to specialised care plans for / [ x] Medications[ ] Pain management[ ] Wound care
[x ] Therapy[ ] Restraint management
Social and human needs/activities
Care needs: Potential for social isolation
Goal: (expected outcome) To ensure Ethel has opportunities to develop meaningful relationships and communication
Frequency of visit/contact by family/friends Both children, their partners and grandchildren live in USA. Husband died 3 months ago. Has no siblings. Phone call contact weekly by family.
Religion beliefs/practices Nil
Pastoral requirements Attends place of worship (day/s )
Cultural needs
Hobbies/interests Bingo, Horse racing, Reading Employment history Retired manager of retail store
Behaviour
Care needs: Currently experiencing grieving process related to husbands death, her stroke, and relocating to nursing home care
Goal: (expected outcome) To allow Ethel to express her grief
Allow Ethel time to talk
Validate her feelings
Respect Ethel’s need for privacy
Facilitate opportunities for Ethel to talk with other residents
Encourage Ethel to make use of the chaplaincy service if she wishes
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
Barbara Thomas RN
Grange House use only
Entered in progress notesDate Today
Signed Barbara ThomasPrint name Barbara ThomasPosition title RN
Review date every 3 months

Grange HouseCare planPage 1 of 5