Care Plan

Care alerts(write in red) For example: allergies, drug reactions, smoker, falls risk, diabetic
Smoker. Falls Risk. Allergic to aspirin.
Communication
Preferred name: Cindy
Care needs:
Goal: (expected outcome)
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 -
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
Speech disorder/s
Translate for resident
Take time to listen
Initiate conversation
Use language cards
Use picture cards
Other
Mobility
Care needs:
Goal: (expected outcome)
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 / Toilet (times )
Other self catheterises 4-6 times per day. Incontinent of urine if has large alcohol intake
Bowel control / continent incontinent constipation colostomy ( occasionally frequently total incontinence )
Bowel management / high fibre dietencourage fluid intake aperients bowel chart
Continence aids / Day / Night pad
Toileting
Toileting aids / commodeurinaluridomekyliebed pan
over-toilet frame Other
Toileting regime / independentsupervisesome assistance/promptfully assist
Adjust clothingPosition on toiletEncourage self care Clean perianal area
Other
Showering, dressing and grooming
Care needs:
Goal: (expected outcome)
Shower and washing
independentsupervisesome assistance/promptfully assist
showerbathbed spongeflannel wash
FrequencyPreferred time
Adjust water temperatureEncourage to optimise self care
Other
Transfer / walk to showerwheelchairOther
Showering aids / shower chairOther
Toiletries / normal soapdeodorantaqueous creammoisturiser ( am pm )
Other
Hair care / wash in showerwash in bathPreferred days Daily
Grooming
Hair care / independentsupervisesome assistance/promptfully assist
Hairdresser
Facial hairwet shavedry shaveFrequency
Hair removal Frequency
Nail/foot care / independentsupervisesome assistance/promptfully assist
Podiatry visits
Teeth / nonesome ( upper lower )all
Cleaning routine
Dentures / nonepartialfull( upper lower )Nightinout
Cleaning routine
Dressing and undressing
independentsupervisesome assistance/promptfully assist
calliperssplintsOther
Cultural dressing
Dressing assistance / bra singletbuttonsbeltzips
stockingssocksjewellery make-upshoes
Assist with selecting clothingOther
Pressure area and skin care
Care needs:
Goal: (expected outcome)
Norton Scale / Score[X ] 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
Eating and drinking
Care needs:
Goal: (expected outcome)
Eating
independentsupervisesome assistance/promptfully assist
right-handedleft-handed
Preferred place to eat / dining roombedroomOther Kitchen
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
independentsupervisesome assistance/promptfully assist
right-handedleft-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 0830Usual time to bed 10 pmRest time( am pm )

Preferred sleeping position Back supported by pillowsPillows required 3

Sleep Aids / massagemusichot packsOther
Room / light ondoor opendoor closedbedrail/protectorsOther
Night-time patterns / Sleeps for 6-8 hours without waking
Other preferences (For example: hot drinks or snacks)
Night checks / every hourevery 2 hours Other
Medications

Current medications

/

eye dropsear dropsOther

independentsupervisesome assistance/promptfully assist
pre-packedmeasureself-administer

Blood sugar level testing

/ independentsupervisesome assistance/promptfully assist

Frequency

Specialised care plans
Refer to specialised care plans for / [X ]Medications
[ ]Pain management[ ]Wound care
[ ]Therapy[ ]Restraint management
OHS
Completed injury risk assessment forms / Home environmentYesNo
Client assessmentYesNo
Social and human needs/activities
Care needs: Frequent visits from family and friends
Goal: (expected outcome) Social Contacts are maintained
Frequency of visit/contact by family/friends Mother visits 2nd Daily. 2 sisters live interstate
Religion beliefs/practices
Pastoral requirementsAttends place of worship (day/s )
Cultural needs
Hobbies/interests Listening to music, reading, sewingEmployment history Registered Nurse for 10 years
PetsName/sType/s
client manages petrequires prompt and assistance in pet carefully assist pet care
Social group/s Goes to choir practice weekly at Community Centre
Preferred activity/games Wheelchair netball, swimming
Community care social outings Janderby Community Centre(Frequency weekly )
Requirements Maxi Taxi for wheelchair
Taxi vouchersYesNo
Domestic needs/activities
independentsupervisesome assistance/promptfully assist
Frequency ( dailyevery 2nd dayweeklyfortnightlyOther )
Requirements / Shopping
Washing clothes
Cleaning
Cooking
Transport
Gardening

Other

Emotional support
Establish level of emotional support daily
Encourage to attend M.S. support group
Promote healthy lifestyle without use of alcohol and “soft” drugs
Encourage to attend weekly counselling sessions with psychotherapist
Discuss attendance at Al-Anon meeting
Provide information about Al-Anon groups
Behaviour
Care needs: Client becomes aggressive after alcohol abuse
Goal: (expected outcome) Reduce number of aggressive incidents
  1. Client has just ended a five year relationship. Incidents of alcohol abuse have increased to weekly. Client becomes verbally aggressive and at risk for falling from wheelchair. Psychotherapist has reported that client has missed last four appointments.
  2. Client has been encouraged to attend Al-Anon meetings.

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
S.Ward(S.Ward Senior Care Worker)
Grange Community Care use only
Entered in progress notes YesDate
Signed S.WardPrint name Samantha WardPosition title Senior Care Worker
Review date every 3 months

Grange Home CareCare PlanPage 1 of 5