Care plan

Care alerts(write in red) For example: allergies, drug reactions, smoker, falls risk, diabetic
Falls Risk

Name of Doctor: Dr Alan Trudeaux Contact No: 07 222 5555

Communication
Preferred name: Florence
Care needs:Hearing and Vision Impairment
Goal: (expected outcome)Effective two way communication will be maintained
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 / OtherRemind to fit aids .Remind to attend audiologist
Eye care required / Ear care required
Speech and language / Comprehension issues(For example: inappropriate responses)
Language/s spokenEnglish
Short term memory loss
Unable to remember regular appointments
Speech disorder/s
Translate for client
Take time to listen
Initiate conversation
Use language cards
Use picture cards
Other
Mobility
Care needs:Slow gait, uses walking stick, related to arthritic knees.
Goal: (expected outcome)Current level of mobility will be maintained safety
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)Client will remain comfortable and dry
Continence
Bladder control / continentincontinentcatheter( occasionally frequently total incontinence )
Bladder management / fluid balance charttoilet ( Prompt to toilet when attending to client )
Other
Bowel control / continentincontinent constipationcolostomy( occasionally frequently total incontinence )
Bowel management / high fibre dietencourage fluid intakeaperients bowel chart
Continence aids / DaySmall Day Pad / NightSmall Night Pad
Toileting
Toileting aids / commodeurinaluridomekyliebed pan
OtherPlace pad in place after assisting with shower.
Toileting regime / independentsupervisesome assistance/prompt fully assist
Adjust clothingPosition on toiletEncourage self care Clean perianal area
Other
Showering, dressing and grooming
Care needs:Unable to meet hygiene needs independently due to stiff and painful needs related to arthritis
Goal: (expected outcome)Clients personal hygiene needs will be met. Privacy and dignity will be optimised.
Shower and washing
independentsupervisesome assistance/promptfully assist
showerbathspa bathbed spongeflannel wash
Frequency2nd DailyPreferred time 0900hrs
Adjust water temperatureEncourage to optimise self care
Other
Transfer / walk to showerwheelchairOtherMobile shower chair
Showering aids / bath trolleyshower chairOtherMobile shower chair
Toiletries / normal soapdeodorantaqueous creammoisturiser ( am pm )
Other
Hair care / wash in showerwash in bathPreferred days
Dressing and undressing
independentsupervisesome assistance/promptfully assist
callipers splints Other
Cultural dressing
Dressing assistance / brasinglet buttons belt zips
stockingssocksjewellery make-upshoes
Assist with selecting clothingOther Assist to remove clothing before shower.
Grooming
Hair care / independentsupervisesome assistance/promptfully assist
Hairdresser Hair washed at hairdresser weekly
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 ) Night inout
Cleaning routineEncourage to clean after breakfast with toothpaste
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
Eating and drinking
Care needs:Unable to prepare own meals
Goal: (expected outcome)Meals will be prepared three times per week by care worker. Adequate nutrition and hydration will be maintained
Eating
independentsupervisesome assistance/promptfully assist
right-handedleft-handed
Preferred place to eat / dining roombedroomOtherKitchen
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:Wakes once overnight to toilet
Goal: (expected outcome)Client will receive adequate sleep and rest and will remain comfortable overnight.
Usual time to rise 0800hrsUsual time to bed1930hrsRest time( am pm )

Preferred sleeping positionOn left side Pillows required2

Sleep Aids / massagemusichot packs Other
Room / light ondoor opendoor closedbedrail/protectorsOther
Night-time patterns / Wakes once overnight to toilet
Other preferences (For example: hot drinks or snacks)
Night checks / every hourevery 2 hours Other
Specialised care plans
Refer to specialised care plans for / [ ] Medications Check, is there enough space to write medications, or make changes?
Current medications independent pre-packed
1 NB: See Dr’s list of prompt/supervise measure
Medication. fully assist self administer
eye drops ear drops
Blood Sugar Level testing Frequency………… Independent
Prompt/supervise
Fully assist
[ x ] Pain management[ ] Wound care
[ ] Therapy[ ] Restraint management
Social and human needs/activities
Care needs:Sometimes withdraws related to social isolation and hearing problems
Goal: (expected outcome)Client will socialise and overcome withdrawn state
Frequency of visit/contact by family/friendsDaughter visits 2nd daily
Religion beliefs/practicesRoman Catholic
Pastoral requirements Attends place of worship (day/s Sunday )
Cultural needs
Hobbies/interestsGardening Knitting Employment historyWorked in Department Store Supervisor
Pets Name/s _Bluey______Type/s____Budgie______
client manages pet client requires prompt & assistance in pet care fully assist pet care
______
DOMESTIC NEEDS/ACTIVITIES
Requirement Frequency – daily independent
2nd daily supervise
weekly some assist/prompt
fortnightly fully assist
Shopping………Weekly…………………………………………………………………………………………………
Washing clothes…Weekly……………………………………………………………………………………………….
Cleaning………Weekly………………………………………………………………………………………………….
Cooking 3 times per week…………………………………………………………………………………………………..
Transport…Weekly……………………………………………………………………………………………………….
Gardening…Weekly………………………………………………………………………………………………………
Other………………………………………………………………………………………………………………
______
OSH Completed Injury Risk Assessment Forms : Home Environment Yes No
: Client Assessment Yes No
Is this necessary in a Care Plan, the form would need to be reviewed 3/12. Sounds like it is an initial assessment.
I personally like it to be thorough and make sure the OSH assessments have been done.
______
EMOTIONAL SUPPORT
Type:Provide support each visit, enjoys talking, sitting in Garden.……………………………………………………………………………………………………………………..
______
SOCIAL ACTIVITIES
Social group/s …Church group………………………………………………………………………………………
Preferred activity/games……Knitting, PlayingCards………………………………………………………………………….
Community Care social outings Frequency …Monthly…………………………………………………..
Requirement……………………………………………………………………………………………
Taxi vouchers Yes No
Behaviour
Care needs:Nil
Goal: (expected outcome)
Additional comments (For example: special needs, restraint, routines, pain, palliative care, pacemaker)
Encourage client to speak with Dr if knees are painful
Terminal care recorded YesNo
Date care plan evaluated (document in progress notes) / Signature
S Ward
Grange House use only
Entered in progress notesDate
SignedSWardPrint nameSamantha WardPosition titleSenior Care Worker
Review date every 3 months

Grange Home CareCare planPage 1 of 6