Care plan

Care alerts(write in red) For example: allergies, drug reactions, smoker, falls risk, diabetic
Dust mite allergy
Communication
Preferred name: Bob
Care needs: Hearing and visual impairment
Goal: (expected outcome)Effective two-way communication 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 -
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
Speech disorder/s
Translate for care recipient
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: Frequent urinary incontinence and occasional bowel incontinence
Goal: (expected outcome) To remain dry and comfortable at all times
Continence
Bladder control / continentincontinentcatheter ( occasionally frequently total incontinence )
Bladder management / Toilet (times0800 1200 1600 2000 )
Other Prefer s male care worker
Bowel control / continent incontinent constipation colostomy ( occasionallyfrequently total incontinence )
Bowel management / high fibre dietencourage fluid intake aperients bowel chart
Continence aids / Day medium pad / Night night pad
Toileting
Toileting aids / commodeurinal at nighturidomekyliebed 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 Prefers male care worker
Transfer / walk to showerwheelchairOther
Showering aids / shower chairOther
Toiletries / normal soapdeodorantaqueous creammoisturiser ( am pm )
Other
Hair care / wash in showerwash in bathPreferred days Wednesday
Grooming
Hair care / independentsupervisesome assistance/promptfully assist
Hairdresser
Facial hairwet shavedry shaveFrequency Daily
Hair removal Frequency
Nail/foot care / independentsupervisesome assistance/promptfully assist
Podiatry visitsPodiatry visits for toenails
Teeth / nonesome ( upper lower )all
Cleaning routine
Dentures / nonepartialfull( upper lower )Nightinout
Cleaning routinesoak dentures
Dressing and undressing
independentsupervisesome assistance/promptfully assist
calliperssplintsOther
Cultural dressing
Dressing assistance / brasinglet buttonsbeltzips
stockingssocksjewellery make-upshoes
Assist with selecting clothingOther
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:
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
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 0700Usual time to bed 2100Rest time( am 1 – 3 pm )

Preferred sleeping positionSleeps on left sidePillows required 1

Sleep Aids / massage musichot packsOther
Room / light ondoor opendoor closedbedrail/protectorsOther
Night-time patterns / Wakes to toilet self once overnight
Other preferences (For example: hot drinks or snacks) / Milo and 2 biscuits
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
[ x]Therapy[ ]Restraint management
OHS
Completed injury risk assessment forms / Home environmentYesNo
Client assessmentYesNo
Social and human needs/activities
Care needs:
Goal: (expected outcome)
Frequency of visit/contact by family/friends Daughter, Jane Marino, visits several times during the week. Friendship with neighbours – daily contacts.
Religion beliefs/practices Anglican
Pastoral requirementsAttends place of worship (day/s Sunday and religious holidays )
Cultural needs
Hobbies/interests Reading, boats, woodwork, lawn bowlsEmployment historyRetired school teacher
Pets BudgerigarName/s BuddyType/s Bird
client manages petrequires prompt and assistance in pet carefully assist pet care
Social group/s Mooring Lawn Bowls Club
Preferred activity/games Lawn Bowls - is picked up and dropped off by friends
Community care social outings(Frequency Tuesdays )
Requirements
Taxi vouchersYesNo
Domestic needs/activities
independentsupervisesome assistance/promptfully assist
Frequency ( dailyevery 2nd dayweeklyfortnightlyOther )
Requirements / Shopping
Washing clothes
Cleaning
Cooking
Transport
Gardening

Other

Emotional support
Mr Farrell’s wife Joan died three years ago from breast cancer and requires support at times, around Joan’s birthday May 30th and the anniversary of her death, February 7th .
Behaviour
Care needs:
Goal: (expected outcome)
Short term memory loss
Additional comments (For example: special needs, restraint, routines, pain, palliative care, pacemaker)
Bob prefers male care worker for toileting and showering activities.
Terminal care recorded YesNo
Date care plan evaluated (document in progress notes) / Signature
Tanya Tomlinson RN
Grange Community Care use only
Entered in progress notes YesDate
Signed Tanya Tomlinson RNPrint nameTanya TomlinsonPosition title Care Manager
Review date every 3 months

Grange Home CareCare planPage 1 of 5