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TAME THE CARE PLAN MONSTER

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Taming the Care Plan Monster

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POST TEST

1. Which of the following is a part of a care plan?

a. Physician orders

b. Medication sheets

c. Target behavior monitoring sheets

d. All of the above

2. Which of the following is not a “Standard” of care?

a. Provide privacy

b. Provide diet as ordered based on likes and dislikes

c. Incontinent care

d. None of the above

3. What is the benefit of listing contributing factors on the care plan?

a. Explains why certain interventions are chosen

b. Individualizes the care plan

c. More resident centered

d. All of the above

4. Which statement below is false?

a. Everything that you do should be on the problem oriented care plan

b. Problems should be resident centered not discipline centered

5. Which statement below is true?

a. Resident functional status can be measured

b. Goals should be daily



POST TEST ANSWERS

1. Which of the following items is part of a care plan?

a. Physician orders

b. Medication sheets

c. Target behavior monitoring sheets

d. All of the above

2. Which of the following is not a “Standard” of care?

a. Provide privacy

b. Provide diet as ordered based on likes and dislikes

c. Incontinent care

d. None of the above

3. What is the benefit of listing contributing factors on the care plan?

a. Explains why certain interventions are chosen

b. Individualizes the care plan

c. More resident centered

d. All of the above

4. Which statement below is false?

a. Everything that you do should be on the problem oriented care plan

b. Problems should be resident centered not discipline centered

5. Which statement below is true?

a. Resident functional status can be measured

b. Goals should be daily

D

C

D

A

A


Resident Centered I di id li dIndividualized

Care Plans

TAME THE CARE PLAN

POLARIS GROUP Strategic Solutions For Healthcare www.polaris-group.com©

MONSTER

1

Care Planning

• Develop care planning policies which definesh i “ l ”what constitutes your “care plan.”

• It is impossible to put “Everything you do” on aproblem-oriented care plan in one part of thechart.

• Create a workable care plan and defend process


Create a workable care plan and defend processwith surveyors.

• Consider three (or four) parts of the Plan ofCare.

2


Care Planning

• Part One: The entire medical record reflects all services, diagnosis, medications; Entire Plan of Carev , g , ;

• Physician orders, medications sheets, treatment sheets.

• Diagnosis lists.

• Behavior sheets reflect target behaviors and


ginterventions.

• ADL sheets

• Progress notes reflect service provision. 3

Care Planning

• Part Two: The Problem-oriented care plan dd ifi bl / d / i k haddresses specific problems/needs/risks that are

unique for the resident and require interventions beyond “standards” of care.

• Wh t d thi ?


• What does this mean?

4


Care Planning

Part Two: Continued

P bl i d l dd bl• Problem-oriented care plans address problems for the resident that requires individualized interventions or exceptions to Standards.

• Many problems require an interdisciplinary approach.


approach.

• Problems that require measurable goals to monitor effectiveness of care plan.

5

Care Planning

Part Two: Continued

• Problems are not necessarily every medical• Problems are not necessarily every medical diagnosis or medication unless condition is acute or unstable. But do consider high risk and acute medical diagnosis and/or medications.

• It would be unreasonable and impossible to put


“everything we do” for the resident on the problem-oriented care plan form.

6


Care Planning

Part Two: Continued

Mi i i li i “ d d ” f h l• Minimize listing “standards” of care that apply to all residents, but these are in writing and known to staff.

• Minimizing writing out in detail all “protocols” for specific care needs as these are in procedures


for specific care needs as these are in procedures but these must be known and available to staff.

7

Care Planning

• Part Three:

– Aide Care Plan Face Sheet with “need to know” information for care delivery.

– For example, the resident may wear dentures. There is no “problem” with


the dentures, but the aide needs to know the resident wears dentures.

8


Care Planning

• Part Four:

• Optional - A Resident-Centered “I” care plannarrative can be added to address residenthistory, likes and dislikes, daily routines, andactivities etc. This method may be added when afacility is implementing a more resident-centered


y p gculture.

9

“I” Care Plans

• Care plan written in “first person”

• Usually more “narrative”

• Provides more background information

• Less problem/goal oriented

• More focused in resident preferences


• The above can be accomplished without “I” care plan format

10


“I” Care Plans


11

“I” Care Plans


12


“I” Care Plans


13

Care Planning

• Standards of Care: Standards of care are d i i i h l ll idprocedures in writing that apply to all residents

regardless of resident’s status. The facility should identify and formalize all standards. After completion, the problem-oriented care plan would not need to list these as


interventions, but would address “exceptions” to standards of care.

14


Care Planning Standards of Care

– Keep call light within – Weigh monthly.

Meals as orderedp g

reach.

– Evening snack available and offered.

– Monitoring for medical changes.

– Meals as ordered.

– Medications or treatments as ordered.

– Provide privacy.

– Fluids available at bedside d ff d d i


g

– Monitoring for adverse reactions or side effects of medications/treatments.

and offered during care.

– Activity calendar provided weekly.

– Respond timely to call light.15

Care Planning Care Protocols

Care Protocols: Care protocols are in writing and areil bl ff C l fl d favailable to staff. Care protocols reflect procedures for

certain care areas that the facility’s QA function hasapproved. For example, a Bowel Movement Protocolor procedures for incontinent care are care protocols.The protocol is constant, but the care need will dependon the individual resident. The care plan can refer to


on the individual resident. The care plan can refer tothe care protocol e.g. incontinent care protocol. Ofcourse the problem-oriented care plan would alsoaddress exceptions to protocol.

16


Care Planning Care Protocols

• Catheter care is a protocol

• Peri-care procedures for• Weight loss protocols

• Many procedures can be inPeri care procedures for cleaning is a protocol

• Nursing procedures e.g. diabetic nail care, blood sugars.

• How you suction a resident is a protocol/procedure

• Many procedures can be in basic nursing protocol format and include infection control practices.

• Protocols for high risk medications e g Coumadin


protocol/procedure.

• Protocols for medical issues e.g. hypertension, tube feedings, etc.

medications e.g. Coumadin, antipsychotics, etc.

• Protocols for high risk medical diagnosis

17

Admission Care Plan

ADMISSION CARE PLANS: Master your problem list.

B d li i I i i l C• Based on your preliminary assessment, an Initial Care Plan is established.

• Initiate and modify during the first 14 to 21 days of admit. (The requirement for a comprehensive, interdisciplinary care plan is “within 7 days” of completion of the CAAs)


completion of the CAAs).

• If the resident is not a short stay resident (under 21 days) a designated nurse (MDSC) may take the lead in starting a comprehensive care plan.

18


Considered Using Formatted Care Plan at Admission

• Apply Standard of Care at admission.

• Modify interventions as you get to know the resident.– Complete Risk Assessments

• Focus on key problems especially if Medicare Resident admitted for short stay


Resident admitted for short stay.

• Initiate Aide Communication system to minimize risk of early negative outcomes.

19

Considered Using Formatted Care Plan at Admission


20


Communication with Aides

• How to communicate care interventions with Aides?

• Aide Communication system to minimize risk of early negative outcomes– Verbally

– Quick reference


– EMR print-out

– Aide shift documentation

– Kardex

– Cues in room 21

Communication with Aides


22


Individualized Care Plans Startwith Assessment


23

Care Area Assessment Documentation

• Assessment/CAA Summary includes:

– Description of the problem, could include the presence or lack of objective data and subjective complaints

– Causes and contributing factors

– Complications and risk factors


– Need for referrals or further evaluation to health professionals

– Document reason care plan will/will not be developed 24


SO

Nature of the Problem / Need / Condition(triggers, current status, subjective / objective data)

D

Complications / Risk / Contributing Factorsto be considered or ruled out as influencing the care

A

to be considered or ruled-out as influencing the care planning decision. Factors that influence

individualized care plan interventions. Document key factors influencing decision-making process and

key care plan focus/interventions.

A

P Need or Lack of Need P


25

P for referral to appropriate health care professional. P

Decision to proceed or not to proceedwith interdisciplinary care planning.

Working the CAAs

• Rule out or identify contributors to status and care planning focus:care planning focus:– Subjective/objective observations/data– Medical conditions; lab values – Health conditions– Pain– Medications


– Environment– Sensory losses– Psychosocial /mental status– Functional/physical losses 26


Working the CAAs

• Medical Condition/Health Condition/Pain: MostCAAs list specific medical and health conditions that canpcontribute to, cause, or influence resident’s performance (MDSoutcomes). If the resident has a risk condition listed in the CAA,comment on it! (This includes Mental Illness) Note if themedical status can be improved or stabilized.

• Medications: Most CAAs list risk medications that couldcontribute to resident’s status If they are receiving a “RISK”


contribute to resident s status. If they are receiving a RISKdrug (med is listed in CAA) comment whether or not it isinfluencing MDS outcomes/answers, even if reduction is notappropriate.

27

Working the CAAs

• Environment: Some CAAs ask you to evaluate environmental factors which if could be modifiedenvironmental factors, which if could be modified, would improve resident’s outcomes. Based on strengths or weaknesses, interventions to be implemented to improve outcomes (e.g., vision is good, use visual cues).

• Sensory Losses: The loss of vision, hearing, or the


y , g,ability to communicate usually contributes to resident performance. These should be commented on and considered when care planning.

28


Working the CAAs• Psychosocial: This area has three main focuses.

– Impact of grieving or losses. Losses can be loss of home,abilities, dog, roommate; anything that is a loss to theresident. Most care plans could better address the supportneeded to cope with loss.

– Relationship issues and the impact on resident performance.

– Implementation of preferences and customary routine.

F ti l Ph i l L Th b d di i t


• Functional Physical Losses: These go beyond diagnosis toactual functional status and its influence on performance andcare planning. For example, contractures, inability to graspobjects, inability to bear weight, etc.

29

Working the CAAs Tips: • Address what “triggered the CAA”

D t ti t l/ li ti f t• Document pertinent causal/complicating factors contributing to the decline/clinical outcome.

• Acknowledge all contributing factors even if obvious, e.g. decline is due to vision loss.

• Indicate if improvement can be made or not to justify h i f i i l


choice of a maintenance or improvement goal.

• Document focus of care plan decision.

• May document a summary note, integrate into assessments, CAA Guideline/Software module.

30


Using the CAAs to develop the Care Plan


31

Resident Centered Care Plans

• Comprehensive, Individualized care plan based on comprehensive assessmentp v– Interdisciplinary assessments

• Ongoing care plan that is reviewed at least quarterly.

• Ask aides to help keep current


– Continue to have Aide Care Plan communication.

• Continue to consider the entire medical record as the plan of care.

32


Care Planning

• How do you individualize?– CAA header/Problem/Need – resident centered

not discipline centered

• As Evidence by (AEB)s

– Describes current status (Also used to


individualize interventions)

» Contributing factors (CF)

» Factors Identified in CAA33

Resident Centered Care PlansProblem/Need Statements

Resident-centered problems/needs/risks

• F n 5 r 6 k r f r r id nt• Focus on 5 or 6 key areas for a resident.

• Consider using more CAA language and less nursing diagnosis or more descriptive.

• Problems are resident-oriented not discipline-oriented.


oriented.

• Individualize the resident problem with subjective or objective information.

34




• Alt r d N triti n l St t• Altered Nutritional Status

• At risk for weight loss

• Under weight

• Losing weight

F il h i


• Failure to thrive

35



• At ri k f r f ll• At risk for falls

• At risk for repeat falls

• At risk for an injury fall

• Risk for Pressure Ulcer

Ri k f l


• Risk for repeat pressure ulcer

• Actual pressure ulcer

36


As Evidenced By

As evidenced by (AEB) is objective, observable descriptors of resident’s status, similar to MDS data, describe well enough to help build a measurable “Outcome Statement”


– Crying, limited assist with grooming, weight, falls, contractures, etc.

– Repeat falls, current weight, or amount underweight. 37

As Evidenced By (use for Interventions)

– Needs only cueing to finish meal.

N d f ll i i h i fl id d lid– Needs full assistance with eating fluids and solids.

– Unable to use utensils, eats finger food or from glass or bowl.

– Resistant to care during daily care which can escalate to biting and pinching.


– Cries easily, grunts when in pain.

– 1 person limited assist with transfers

– Ambulates 50 feet.

– Frequently incontinent of urine 38


Contributing Factors Identified in CAA

Contributing Factors (CF) influence i di id li d i i F l hindividualized intervention. For example, the AEB is actual weight loss.

– One resident’s CF’s are mood decline, pain, loss of appetite, recent loss of spouse.

– Another resident with same AEB of weight


– Another resident with same AEB of weight loss has CFs of failure to thrive, difficulty swallowing, vision and hearing loss. Their interventions would be different

39


• Contributing factors can be both strengths and k d h ld di l fweaknesses and should come directly from

CAA--what did you say were the key contributors to decline or status?

– Mood decline

• crying sad expression


crying, sad expression

–CF: pain, loss of hope, vision loss

–Relationship with Daughter

–Strong spiritual beliefs 40



• Contributing factors INTERDISPLINARY

– Different disciplines may identify different contributors.

• Social Service may identify relationship with daughter

• A ti iti id tif di i ti iti


• Activities may identify diversion activities

41

Outcomes/Goals

• Move away from writing goals, change format to i doutcome oriented statements

• Visualize desired resident outcome as a result of the team interventions you are putting in place.– The “Resident will…….”

– The “Resident will express ”


The Resident will express….

– Use first name if you like that style e.g. “John will...” if that is resident’s preference

42


Outcomes/Goals

• Consider residents status now, then look ahead 3 h d h ld b h d f ?months and what status would be hoped for?

Improved? Risk for decline?

• If risk for decline, then maintaining would be a reasonable outcome. If very high risk, be realistic what you would hope for in three months.


y p

• The thinking process is; resident status now and the outcome goal is resident desired status in three months.

43

Outcomes/Goals

• Resident centered: Use AEB to develop.

• Think functional status.

• Currently a “2” in incontinence on MDS: Goal is to be able to code as a 1….think functional outcomes with MDS as measuring stick.

• Multiple outcomes per one need statement is allowed.


p p

• Put time frame to measure success of interventions.

44


Outcomes/Goals

• Focus on maintaining current, specific highest level of functioning.

• Also focus on resident desires such as their preferred schedule and wishes. – Customary routine is always individualized.


45

Outcomes/Goals

– Resident expresses satisfaction with…

R id nt ill hi ti f t r p in l l– Resident will achieve satisfactory pain levels

– Resident will not leave center unaccompanied.

– Resident continues to self-direct care will full knowledge of risks.

Resident will receive care as resident will allow


– Resident will receive care as resident will allow with no episodes of biting staff.

– John will have on average less than 3 incontinent episodes during waking hours a week. 46


Outcomes/Goals

– “Resident will not experience increased li i i f hi d h ld j i ” ilimitations of hips and shoulder joints” is outcome oriented. The AEB describes the current status of contractures in measurable terms.

• “Provide ROM daily during care” is an


y gintervention not a goal/outcome.

47

Outcomes/Goals

– Keep clean and dry” is a staff goal or i iintervention.

• “Resident will not experience any skin breakdown related to episodes of incontinence”

• “Resident “John” will not experience any


Resident John will not experience any complications as a result of total dependence on staff for care needs.”

48


Outcomes/Goals

• Consider care planning psychosocial well-being d li i k f d li i l didecline or risk for decline as a category, including leisure activities. – “John will continue to self-direct care with full

knowledge of risk to his health”

– “Resident will express satisfaction with leisure


activities.”

– “Resident will benefit from touching and sensory stimulation.”

49

Interventions

• This is where the care plan is interdisciplinary.

• What can my discipline do to help resident maintain or improve status.

• Do not include standards of care.

• Paint a picture what to do.


• Reference protocols as appropriate.

50


Interventions

• Date when start, change, delete.

– Permanent Record

– Treat the same as a med sheet

– Date and Initial


51

Stay Resident Centered

• Many problems and needs are interrelated, so i i i C id bi imerging is appropriate. Consider combining a

problem/need/risk when you note that the interventions are repeating themselves. – ADL and elimination

– Weight loss and hydration risk


g y

– Elimination and Pressure Ulcers

– Behaviors/Mood/Psychoactive meds

– Mood and Activities 52



All problems/needs/risks are dated when added to h bl i d l Th i i i lthe problem-oriented care plan. That initial

date should not be changed. – If reprint care plan, keep original dates

• All disciplines identify contributing factors. The contributing factors are identified in the CAA.


contributing factors are identified in the CAA.– Instead of adding a new problem; add a new

contributor to an existing problem.

53


• All disciplines can write on the care plan in pen i h i i i l d dwith initial and dates.

• Do not duplicate problem. – Mood as one problem

– Behaviors as another problem

– When AEB and interventions are basically the same


– When AEB and interventions are basically the same.

• Focus on adding contributors, interventions and outcomes.

54



55


56



57

Case Studies

• SAMPLES

• CAAs and Care Plan


58


Change in Condition

• Acute New Problem – short term –

– Create Temporary Problem

• UTI

• Flu

• Skin tear


• New Ongoing Problem– Add to care plan and review in risk meeting

59

Change in Condition

The problem or risk for problem is already l dcare planned:

• Do not create a new problem if the problem isalready on the care plan. If you treat a change asa new problem the interventions would be inconflict.


60


Change in Condition

• For example, at risk for falls is already on thel d bl dd h f llcare plan; under problem statement, add the fall

and date, then review and add or deleteinterventions with date and initials. If repeatfalls, change goal to “prevent injury”.

• Pressure Ulcer – Same type of update as for


yp pfalls, but ensure preventive measures arereviewed and revised. Add a new goal to heal,but the preventive goal remains.

61

Change in Condition

• If problem is related to ADLs, weight l /h d i li i i d hloss/hydration, or elimination, update those interventions.

• Behaviors and psychoactive drugs for behaviors are care planned together with updates as needed to new behavior symptoms, mood, or


y p , ,drugs.

62


Case Studies

• CASE STUDIES

• Assessments, CAAs, and Care plan – Updates for changes are noted


63


Overview: 1. Develop care planning policies which define what constitutes your “care plan.” It is

impossible to put “Everything you do” on a problem-oriented care plan in one part of the chart.

2. There are three (or four) parts of the Plan of Care:

Part One: The entire medical record reflects all services, diagnosis, medications; Entire Plan of Care

i. Physician orders, medications sheets, treatment sheets. ii. Diagnosis lists.

iii. Behavior sheets reflect target behaviors and interventions. iv. ADL sheets v. Progress notes reflect service provision.

Part Two: The Problem-oriented care plan addresses specific problems/needs/risks that are

unique for the resident and require interventions beyond “standards” of care. See definitions below.

i. Problem-oriented care plans address problems for the resident that requires individualized interventions or exceptions to standards.

ii. Many problems require an interdisciplinary approach. iii. Problems that require measurable goals to monitor effectiveness of care

plan. iv. Problems are not necessarily every medical diagnosis or medication unless

condition is acute or unstable. But do consider high risk and acute medical diagnosis and/or medications.

v. It would be unreasonable and impossible to put “everything we do” for the resident on the problem-oriented care plan form.

vi. Does not list “standards” of care that apply to all residents, but these are in writing and known to staff.

vii. Does not write out in detail all “protocols” for specific care needs as these are in procedures but must be known and available to staff.

Part Three: Aide Care Plan Face Sheet with “need to know” information for care delivery

That may not reflect a problem but a need. For example, the resident may wear dentures. There is no “problem” with the dentures, but the aide needs to know the resident wears dentures.

Part Four: Optional - A Resident-Centered “I” care plan narrative can be added to address resident history, likes and dislikes, daily routines, and activities etc. This method may be added when a facility is implementing a more resident-centered culture.


3. Standards of Care: Standards of care are procedures in writing that apply to all residents

regardless of resident’s status. The facility should identify and formalize all standards. After completion, the problem-oriented care plan would not need to list these as interventions, but would address “exceptions” to standards of care. The following are examples of standards of care:

a. Weigh monthly. b. Meals as ordered. c. Medications or treatments as ordered. d. Provide privacy. e. Fluids available at bedside and offered during care. f. Activity calendar provided weekly. g. Respond timely to call light. h. Keep call light within reach. i. Evening snack available and offered. j. Monitoring for medical changes. k. Monitoring for adverse reactions or side effects of medications/treatments.

4. Care Protocols: Care protocols are in writing and are available to staff. Care protocols

reflect procedures for certain care areas that the facility’s QA function has approved. For example, a Bowel Movement Protocol or procedures for incontinent care are care protocols. The protocol is constant, but the care need will depend on the individual resident. The care plan can refer to the care protocol e.g. incontinent care protocol. Of course the problem-oriented care plan would also address exceptions to protocol.

a. Catheter care is a protocol b. Peri-care procedures for cleaning is a protocol c. Nursing procedures e.g. diabetic nail care, blood sugars, tube feedings, etc. d. How you suction a resident is a protocol/procedure. e. Protocols for medical issues e.g. hypertension, tube feedings, etc. f. Pressure Ulcer treatment protocols. g. Weight loss protocols h. Many procedures can be in basic nursing protocol format and include infection

control practices. i. Protocols for high risk medications e.g. Coumadin, antipsychotics, etc. j. Protocols for high risk medical diagnosis.

5. All disciplines should be able to add a problem to the care plan but should never

DUPLICATE a problem. The problems should be resident centered not discipline oriented. 6. All problem-oriented care plans are unique but the following offer some suggestions for key

areas for care planning. Continue with Aide Care Plan Sheet with need to know information that includes such basics as dentures or glasses.

i. Nutrition/hydration/tube feeding ii. ADLs/Contractures/Side Rail use/ Rehab/ Restorative/ vision/

communication/cognitive


iii. Elimination/constipation/catheter (may be combined with ADLs) iv. Behaviors/Mood/Psychoactive drugs v. Safety/Elopement/Fall Risk/restraint use if medically supported

vi. Pressure Ulcer/other skin issues risk vii. Acute or high risk medical problems or medications e.g. diabetes, pain,

terminal viii. Psychosocial/spiritual/mood, activities/leisure issues may include desires and

plans regarding activities.

7. A formal Care Conference is used to assemble participants to review the care plan and revise as needed. Usually a care conference is held within 7 days of completion of the CAA at admission and then quarterly.

a. Invite family and resident. b. If possible hold at a time convenient for family. c. If family cannot attend, share care plan after care conference.

i. Mail to family. ii. Call and review over phone.

d. Have direct care providers contribute to care planning. • Invite to care conference • Have lead aide attend with information from assigned aides • Speak directly with aides prior to care conference

e. Perform assessments and obvious care plan updates prior to care conference. f. Focus on reading the care plan during the care conference. g. Focus on goal achievement and modifications of risk factors that impact goal

revision. h. Each discipline contributes to each problem including family and resident. i. The team may or may not write a care conference summary note. j. Notes may be taken and designated nurse updates to changes. k. A care conference may last on average 15 to 20 minutes. Of course some may be

longer and some shorter. If the family has issues and concerns, schedule it for a longer time frame.

8. All problems/needs/risks should be dated when initiated on care plan. The original start date

should never be changed even if care plan is re-written or re-printed. 9. If you re-print the care plan, consider reprinting at time of Significant Change and/or

Annually. Keep all care plans with handwritten updates in overflow files. 10. All interventions should be dated when added or deleted to the care plan. This is a permanent

document. 11. Consider resident-centered “I” care narrative to bring in the personal approach to care

planning. This approach applies to long term residents. This method does not seem as appropriate for short term residents. The “I” care plan model is supported by some Quality Improvement Organizations (QIOs), and may be a state initiative.


a. This describes the resident’s history, likes and dislikes, and daily routine in first person. It creates a model that each resident is an individual.

b. This model supports resident-centered culture change. c. The resident-centered “I” care narrative can be the fourth component of a

traditional care plan model. d. The “I” care plan could replace the entire care plan if the facility wants to

implement this format. e. The narrative can address all the activity programming that is provided by both

activities and direct care staff. ADMISSION CARE PLANS: Master your problem list.

1. Based on your preliminary assessment, an Initial Care Plan is established. 2. Initiate and modify during the first 14 to 21 days of admit. (The requirement for a

comprehensive, interdisciplinary care plan is “within 7 days” of completion of the CAAs). 3. If the resident is not a short stay resident (under 21 days) a designated nurse (MDS Nurse)

may take the lead in starting a comprehensive care plan.

Aide Care Plan Sheet: In combination with your problem-oriented care plan model, there is a need for direct caregivers to have immediate access to care directives. This is a quick reference format. Where to put the Aide Care Plan Sheet: The following are ideas for where to locate the Aide Care Plan:

1. In aide ADL Book. 2. In aide care plan book. 3. In resident’s room in confidential location e.g. inside closet door, back of bath

door. If needed, obtain a written release.


Standards: 1) Meds as ordered, 2) Tx's as ordered, 3) Diet as orderedDiagnosis: Admit Date:Discharge Plan: Allergies: Side Rails:

CVA/Stroke Rehab Functional/ADL Decline Bladder Training/Foley Bowel Training/Altered bowel ElimGOAL: Achieve Rehab functional goals GOAL: Improve Functional Decline to prior status GOAL: Achieve optimal continence. GOAL: Establish bowel routine

Maintain infection control practicesRehab: Rehab: Encourage fluids: Dietary referral:Grooming/dressing: Grooming/dressing: Foley Cath. Care: Meds as ordered:Bed Mobility Bed Mobility Toilet type: Bowel training:Dining: Dining: Scheduled Toileting:Transfer: Transfer: Monitor elimination pattern colorWalk: Walk: Bladder training: consistence odorToileting: Toileting: R/O cause of incontinence:Splint/Brace Splint/Brace: I&OROM: ROM:

DATE PROBLEM INITIATED: DATE PROBLEM INITIATED: DATE PROBLEM INITIATED: DATE PROBLEM INITIATED:

Discharge Planning Pressure Ulcer/Skin at Risk Pain Management I.V. TherapyGOAL: Achieve discharge as planned GOAL: Prevent/Heal pressure sores GOAL: Experience less pain GOAL: No complicationsInterview resident Tx: Meds: I&O:Interview family: Preventive: I.V. ordersArrange Post-discharge plan: Non-drug interventions:

Position: Weigh every:Monitor pain q shift Monitor for complications:

Supplements: Assess pain tolerance:RD ref:


Fracture/Fractured Hip Cancer: Anticoaqulant Therapy CardiacGOAL: No complications GOAL: Achieve physical & mental Comfort GOAL: No complications GOAL: No complicationsCast Chemo/Radiation: Monitor for S.S bleeding: Assess heart rate B.P. Resps.Positioning: Hospice: Protect from injury: Diet restrictions:Pain: Skin Status: Labs/Meds as ordered: Elevate:

Safety procedures: I&O: Pro times are ordered O2 at: Sats:

WBS Weight/Appetite: Safety measures: Monitor endurance/complications/edemaRehab: Complications: fatigue, attitude Monitor BMs Respiratory Care:

apprehension, NW: Rehab:

Pain Management


Resident: RM/Bed: Physician: MR#

INITIAL CARE PLAN(All Goals to be Achieved within 21 days or less)

Initiate problem with date and initial. Add detail as needed. To D/C, cross thru with date/initial.


Amputation: Type: Anemia Ostomy Feeding Tube

GOAL: Heal without complications GOAL: Minimize complications GOAL: Participate in ostomy care GOAL: No complications

Assess wound site: Monitor for complications: Ostomy protocol: I & O:

Monitor for depression: Monitor nutritional intake: Teach self-care: T.F. Order:

Rehab: Labs: Monitor for complications: ST. ref:

Nsq Restorative: V.S. each shift Monitor for infections at Ostomy site Assess for placement:

Prosthetic Care: Free water:


Fall/Safety Risk: Seizure Disorder: Infection Alert: Type: URI/Pulmonary disease:

GOAL: No injury falls GOAL: Will not injure self or others GOAL: Resolve infection GOAL: Resolve

Assess for risk factors to fall Seizure precautions Monitor for S. S. for infections: Lung sounds, resp.:

Position alarm: Meds: Tx: Cough status:

Encourage to use call light Side rails Wound status/progress monitored Level of consciousness

PT Ref: Respiratory status/progress monitored Tx:

Instruct on safety measures: Other: Suction:

Adaptive Device: VS every shift O2

Low Bed Infection Control: Respiratory Care:


TPN Therapy Respiratory/Tracheostomy G.I. Disorder Terminal Care

GOAL: No complications GOAL: Maintain patent airway GOAL: Decreased symptoms GOAL: Death with dignity

Monitor for infection and complications Lung sounds/cough sounds/Resp.. Nutrition Meds:

Line type: O2 Meds: One-to-one

Flow rate: Suction: Bowel sounds: Hospice:

TX protocol Meds: Monitor BMs for consistency, color, odor Pain Management:

Monitor nutrition: Respiratory Care: I&O Comfort measures:

I&O: Vent Care Protocol: Treatment:



(All Goals to be Achieved within 21 days or less)INITIAL CARE PLAN


Renal Failure With Dialysis UTI alert Diabetic Alert Nutrition altered

GOAL: Experience no complications GOAL: Resolve GOAL: No complications GOA Achieve desired weight/nutrition.

Weigh: I&O Meds: Intake/Appetite:

Assess for S.S. infection & hypovolemia Status of continence: Diet: Diet:

Observe for S.S. bleeding Meds /S.E. Monitor S/S hypo/hyperglycemia Weigh:

Dialysis schedule: Urine color, frequency, burning Glucose scan as ordered: S.T. Ref.

No BP in Shunt arm Labs as ordered: Determine likes/dislikes:

Supplements:


Dehydration/Risk Behavior Symptom Psychotropic Drug Use Mood Symptoms

GOAL: Consume adequate fluids GOAL: Fewer Symptoms GOAL: Benefit without side effects GOAL: Decreased symptoms

I&O Redirect by: Monitor for S.E. Activities:

Determine likes/dislikes Assess Internal Contributors Assess for non-drug interventions Depression scale:

Offer fluids between meals: Assess External Contributors: Trial reduction: Meds:

Monitor for dehydration: R/O Delirium Pharmacist: Ref: Likes to:

Specific Gravity Monitor Behavior or Mood Symptoms S.S. one-to-one


Nausea and Vomiting Physical Restraints Communications Decline Delirium Present

GOAL: Resolve GOAL: Experience no complications GOAL: Increase ability to communicate GOAL: Resolve Acute Condition

Intake Assess for Alternatives Comm. Techniques: Meds:

Monitor for dehydration Restraint reduction initiated: S.T. ref: R/O for acute illness/Labs:

Documentation frequency, amount, Restraint order: Evaluate hearing loss: Orient PRN

Color/consistency of emesis Alternatives: Check ears for wax: Assess for pain/constipation/UTI

Meds: Nursing Restorature:

DATE: DATE: DATE: DATE:




Cognitive Decline Vision Altered Skin Condition (non-decub) Psychosocial Well-being

GOAL: Establish daily routine GOAL: Participate in ADLs to optimal Level GOAL: Resolve GOAL: Excess satisfaction

Task Segments Verbal Cues Treatment Orient to facility

Cue as needed Meds Monitor for infection Activities

Reality orientation PRN Eye exam Preventive One-to-one Social Service

Offer choices Wears Positioning Customary routine

Visual Cues Post surgical care

Involve in daily decisions


Dental Problems Activity Pursuits Altered

GOAL: Resolve GOAL: Activities as desired until discharged

Meds/Tx's achieved

Monitor appetite Introduce to Activities offered

Access oral cavity Interview to interests

Evaluate need for dental exam Evaluate time available

for activities






AIDE CARE PLAN SHEET LAUNDRY: Facility/Family Initial Completion Date _____ Signature _________________________ Check all that apply: I = Independent S = Supervision A = Assist D = Dependent

TRANSFERS: PREVENTIVE ELIMINATION I S A D # Assist: 1 2 Bed Mobility: I S A D Toileting: I S A D Wt. Bearing: Full Partial None Turn Every 1 2 Hours Commode Pan Toilet Urinal Brief Equipment: Hoyer Belt [ ] Special mattress [ ] Incontinent: [ ] Fall Risk [ ] Mob alarm: [ ] Bed

[ ] Ch

[ ] Float heels Toilet before and after meals and HS.

[ ] On Rehab Services [ ] Heel protectors Special Toileting Plan: ____________

RANGE OF MOTION: [ ] Pressure relief in chair _______________________________ Type: Passive Active Resistive [ ] Pad: _____________ [ ] Catheter:

Ext: UR LR UL LL Neck [ ] Skin Tear precautions Position correctly, and empty each shift AM care PM care [ ] In Restorative Program: BEHAVIOR / COGNITIVE [ ] Splint: SELF HELP [ ] Resistive to care [ ] On Rehab services Washing: I S A D [ ] Aggressive/punches

W/C - GERICHAIR: [ ] Agitated/anxious W/C Geri chair No special chair ______________________________

Hair: I S A D [ ] Restless [ ] Paces/wanders in rooms

[ ] Up for Breakfast Oral Care: I S A D TEETH ↑ ↓ NO DENTURES: ↑ ↓ NO PARTIAL: ↑ ↓ NO

[ ] Approach slowly [ ] Up for Lunch [ ] Come back later. [ ] Up for Dinner [ ] Nap in afternoon:

[ ] Offer to toilet [ ] Offer food

Shave: I S A D [ ] Ask if in pain

AMBULATION: [ ] Put back to bed

I S A D # Assist: ______ Nail Care: I S A D COMMUNICATION: Walker Cane Push W/C Dress: I S A D [ ] Hard of Hearing [ ] Walk to bathroom [ ] In Restorative Program [ ] Vision Loss [ ] Walk to dining room [ ] On Rehab Services [ ] Hearing Aid: L / R [ ] Glasses [ ] Walk in hall [ ] Able to communicates Needs:

[ ] In Restorative Program NUTRITION Communication: Verbal/Non-verbal [ ] On Rehab Services Diet: _________________________ Special Needs:__________________

SAFETY ISSUES Ability to Eat: I S A D Cues only ______________________________ Restraint Type:_________________ [ ] scooped plate/guard [ ] On Rehab Services Used in W/C Geri chair other [ ] Special utensils or cup

Released q2h and at bedtime [ ] Aspiration precautions ACTIVITIES

Side Rails [ ] Thickened liquids LIKES: ________________________

[ ] One side: ½, ¾, full, split Eats Where: Breakfast ___________ ______________________________

[ ] Two side: ½ , ¾, full, split Lunch _______ Dinner _________ ______________________________

[ ] low bed Supplements:___________________ RESIDENT'S HISTORY [ ] mat on floor [ ] In Restorative Program ______________________________ [ ] Curved mattress/pillows [ ] On Rehab Services ______________________________

Resident _________________________________Room/Bed _______Review Dates / Initial: ______, ______, _____


COMPREHENSIVE INTERDISCIPLINARY, RESIDENT-CENTERED

PROBLEM-ORIENTED CARE PLANS

1. Meets requirements for a comprehensive care plan. 2. Ongoing care plan that is reviewed at least quarterly. 3. Continue to have Aide Care Plan Sheet. 4. Continue to consider the entire medical record as the plan of care. 5. All disciplines can write on the care plan in pen with initial and dates.

Resident-Centered Problems/Needs/Risk areas statements: 1. Resident-centered problems/needs/risks. 2. Focus on 5 or 6 key areas for a resident. 3. Consider using more CAA language and less nursing diagnosis. 4. Problems are resident-oriented not discipline-oriented. 5. The description of the problem is subjective or objective information. 6. Contributing factors are both strengths and weaknesses. 7. All disciplines identify contributing factors. The contributing factors are identified in the CAA. 8. All problems/needs/risks are dated when added to the problem-oriented care plan. That initial

date should not be changed.

CAA CATEGORY CAA Header:

As Evidenced By:

Contributing

Factors:

“As evidenced by” (AEB) is objective observable descriptors of Resident’s Status, Similar to MDS data, Describe well enough to help build a measurable “Outcome Statement.”

“Contributing Factors” (CF) influence individualized intervention. For example, the AEB is weight loss. One resident’s CF’s are mood decline, pain, loss of appetite, recent loss of spouse. Another resident with same AEB of weight loss has CFs of failure to thrive, difficulty swallowing, vision and hearing loss. Their interventions would be different.


How to individualize the Need Statement: 1. The statement becomes individualized as you list the AEB and the Contributing Factors that are

unique for that resident. These can be “bullet points” but still describe the unique issues of the resident that impacts your choice of interventions and goal.

2. The AEB must be specific as to status at the time care plan is written or reviewed. These are considered when writing the outcome statements. Update AEB status at least quarterly if declined/improved.

a. Needs only cueing to finish meal. b. Needs full assistance with eating fluids and solids. c. Unable to use utensils, eats finger food or from glass or bowl. d. Resistant to care during daily care which can escalate to biting and pinching. e. Cries easily, grunts when in pain. f. 1 person limited assist with transfers g. Ambulates 50 feet. h. Frequently incontinent of urine

3. Many functional losses are a contributor to other functional losses/problems. For example, cognitive loss may be a contributor to ADLs, weight loss, toileting, etc.

4. Team members identify and initiate problems. The team agrees on problem/need/risk areas prior to or at care conference.

5. If a significant change occurs, have a care conference to review care plan. 6. Remember, the Aide Care Plan Sheet address most key interventions for direct care providers. 7. Many problems and needs are interrelated, so merging is appropriate. Consider combining a

problem/need/risk when you note that the interventions are repeating themselves. 8. Some common merged problems/needs/risk areas include:

a. ADL decline as a stand-alone. b. ADLs combined with vision loss, communication issues, and cognitive issues as

contributors to ADL decline. c. ADLs, toileting/constipation, pressure ulcer risk can be combined. d. If resident has a history of a pressure ulcer or an active pressure ulcer, it is suggested it be

care planned as a separate problem. e. Weight loss risk/or active weight loss with hydration risk can be combined. f. Combine toileting with pressure ulcer risk separate for ADLs. g. Psychosocial Well-being, Relationships, and Activities can be combined. h. Mood/Behaviors and then list psychoactive drugs as an intervention if in place are

combined. i. Fall Risk/Safety issues of any kind can be combined. j. High risk medical problems/medications with method to monitor effectiveness.


How to write an outcome statement: 1. Resident-oriented, not discipline specific. 2. Move away from writing goals, change format to outcome oriented statements 3. Visualize desired resident outcome as a result of the team interventions you are putting in place.

a. The “Resident will…….” b. The “Resident will express….” c. Use first name if you like that style e.g. “John will...” if that is resident’s preference

4. Use “As Evidenced By” statements to develop measurable outcomes since these are what you observe and can measure. Use MDS codes as a guide. If the resident's current MDS Code is a “2” for frequently incontinent, then you may want to maintain (Code 2 on next MDS) or improve to a coding of “1” for occasionally incontinent on the next MDS. Use the narrative language.

5. Most outcomes are “reviewed” as to success every three months unless the resident conditions/risk warrants a more short term review.

6. Consider residents status now, then look ahead 3 months and what status would be hoped for? Improved? Risk for decline? If risk for decline, then maintaining would be a reasonable outcome. If very high risk, be realistic what you would hope for in three months. The thinking process is; resident status now and the outcome goal is resident desired status in three months.

7. During the three month time frame the resident’s status may fluctuate but overall the functional status can be measured as MDS is completed and used to help determine if outcome was achieved.

8. Focus on maintaining current, specific highest level of functioning. 9. Also focus on resident desires such as their preferred schedule and wishes. 10. Be outcome oriented not process oriented:

a. “Resident will not experience increased limitations of hips and shoulder joints” is outcome oriented. The AEB describes the current status of contractures in measurable terms.

i. “Provide ROM daily during care” is an intervention not a goal/outcome. b. “Resident will receive care as resident will allow with no episodes of biting staff” c. “Keep clean and dry” is a staff goal or intervention.

i. “Resident will not experience any skin breakdown related to episodes of incontinence”

ii. “Resident “John” will not experience any complications as a result of total dependence on staff for care needs.”

d. “John will have on average less than 3 incontinent episodes during waking hours a week” 11. You can have multiple outcomes statements per problem/need/risk statement based on contributing

factors, merged CAAs or discipline-specific focus/goal. 12. Consider care planning psychosocial well-being decline or risk for decline as a category, including

leisure activities. a. “John will continue to self-direct care with full knowledge of risk to his health” b. “Resident will express satisfaction with leisure activities.” c. “Resident will benefit from touching and sensory stimulation.”


How to write interventions:

1. Date when started and when deleted. Keep original dates just like you would a medication. 2. Strive for interdisciplinary. Each discipline strives to have an intervention for each resident

issue. 3. “What can my discipline do to help meet the desired outcome?” 4. Do not include routine standards of care. (Standard of care are interventions routinely done for

all residents; e.g. weigh monthly) 5. Use Aides to help develop. If an aide cannot actually attend the conference, have a lead aide

attend conference representing the aides. 6. Provide aides with information they need e.g. Aide Care Plan Sheet, interventions for behaviors,

etc. 7. Be individualized, don't just say "redirect"; say how to redirect if known e.g. fantasy validation. 8. If a “protocol” is used e.g. “how you do incontinent care” just indicate “incontinent care

protocol” but aide would need to know what that is. 9. If the intervention is “every two hours,” does everyone know what that means?

1. Toileting plan should be somewhat specific. Do your really mean “toilet” every two hours even during the night.

10. If the facility desires to implement an “I” Resident-Centered narrative, interventions will be in a narrative format with resident details.


NAME: Martin Jones, Call me Marty ROOM #:__8b__ Initiated Date:______________ SOCIAL HISTORY: I was born on a farm in Belknap, Montana in 1915. We raised beef cattle and hay. I went to high School then joined the Army Infantry and fought during WWII in France. In 1956, I married Jane. After we started our family, I took a position with the Standard Oil as a regional manager. In 1980 I retired after 30 years. Hunting, fishing and camping were my favorite pass times. All of us loved camping as a family. We took our five children on trips to all of the National Parks in the Western United States during their summer breaks from school. We have thirteen grandchildren and three great grandchildren. My wife and I moved to the Riverview Retirement Community two years ago when my health began to fail. She lives in an apartment close to the Care Center. ACTIVITIES and MENTAL WELLNESS: I am not able to be out of bed for long. Please visit me regularly and offer support to me and my family. I may respond to you with simple yes or no answers or talk a little. I sometimes get lonely and will press my call button or yell out, just to hear a voice nearby. Just sitting by my bed and gently touching my hand relaxes me. Reading from the Bible has always brought me comfort. I also enjoy stories about the outdoors and about animals. I have always enjoyed the dogs and appreciate Roly at my bedside, please always keep him with me. I have a couple of birds I call “George and Gracie” who are in a cage in the corner of the room. I try to talk to them a little every day so they aren’t lonely. I like you to talk to them too. I’ve always enjoyed people and love to have the volunteer reader come and read me stories. Soft country music by my bedside is familiar and relaxing. I don’t like watching TV anymore.

SPIRITUALITY: I am of Lutheran faith and have attended church regularly for over fifty years.

Someone from my church visits every Tuesday. On Sunday my wife and kids visit together so we can pray as a

family. Offer us privacy with our visits. COMMUNICATION/MEMORY: Be sure to ask me “yes” and “no” questions if I am tired. Sometimes I do not know where I am and I become frightened. Please remind me of my name and where I live. Let me know who you are and what you are going to be doing. I know my children and my spouse. When I am confused and frightened, I may strike out at you. Use calm gentle touch and hand massage while providing me reassurance. PAIN: When I moan when you turn me I am in pain so please tell nurse, I also resist care at times. PERSONAL CARE: I wear glasses when visiting with family, I hear OK. I like wearing flannel pajamas and robe when I am up. You must do all my care. I like the urinal propped when I am in bed, and usually have a BM every third day in AM. It takes two people to move me to the chair. I have on half rail up because that is what I want. I like my showers in the PM. You need to feed me and I choke on occasion. I am on a pureed diet and thick liquids so no water. Review Date/Initial:____________Review Date/Initial:_____________Review Date/Initial:_____________


SAMPLE ONE:

NEED: Decline in ADLs: Should have initial start date. Date all additions and deletions. As evidenced by: • Needs cues to finish meals; occasionally

refuses to eat if tired. • Requires limited assist to dress upper

extremities and grooming • Requires extensive assist to dress lower

extremities. • Limited assist of 1 for transfers • Can turn self in bed with cues • Walks behind wheelchair to meals with

supervision • Likes hair in pony tail

Contributing Factors: • No joint limitations • Arthritis and stiffness in AM • Cannot bend over to dress lower extremities • Decreased vision • Parkinson’s • Motivated to keep walking • Fearful to walk without wheelchair for balance • Prefers evening showers

Note: Merged ADL and Vision and Nutrition CAAs OUTCOME/GOAL: Should have measurable time frame. • Resident will continue to be able to ambulate behind wheelchair to two meals a day. • Resident will continue to dress upper extremities with limited assistance. • Resident does not desire to lose weight but prefers to continue to feed self and not be pushed. INTERVENTIONS: All should be dated. • Likes facial hair removed monthly by

daughter - C.N.A. • Provide set up for grooming at sink while she

sits in wheelchair – C.N.A • Allow resident to assist in dressing upper

extremities with cues – C.N.A. • Full assist with pants and shoes – C.N.A. • Prefers evening showers – C.N.A. • Likes hair in a pony tail - C.N.A.

• Like to wear her sweat outfits – C.N.A. • Like to be up for breakfast – C.N.A. • Encourage and remind her to ambulate behind w/c –

C.N.A. • Prefers to wear slippers not shoes – C.N.A. • Remind to attend morning exercise group M-F - ALL • Shower per schedule in the evening – C.N.A. • Encourage her to finish meals – C.N.A


SAMPLE TWO:

NEED: Decline in ADLs, Incontinent, under ideal weight, risk for skin breakdown or pressure ulcer: Should have initial start date. Date all additions and deletions. As evidenced by: • Unable to fully understand • Moderate limitations of hip and knees • Needs extensive assist with dressing and

grooming and bed mobility. • Extensive assist with eating • Extensive assist of 2 for transfers • Frequent episodes of bowel and bladder

incontinence

Contributing Factors: • CVA with left sided weakness. • Below ideal body weight • Memory loss from dementia • Immobility • Resists assistance in dining at times • Contractures • Inability to grasp and unable to hold utensils or cups • Does not ambulate • Unable to toilet self • Unaware of need to void • Unaware of need for fluids • Mechanical soft diet

Note: Merged ADL, Incontinent, Cognitive, Communication, Nutrition, Hydration, and Pressure Ulcer CAAs OUTCOME/GOAL: Should have measurable time frame. • Resident will not experience an increase in limitations of hips and knee joints. • John will not have a skin excoriation or pressure ulcer. • John will have no more than 3 episodes of incontinence of urine a week during waking hours. • Resident will maintain weight range of ---- to -----. (fill in) INTERVENTIONS: Should be dated. • Feed resident – C.N.A • Provide fluids with meals and during care –

C.N.A • Provide fluids during activities - AD • Prop urinal during waking hours – check

every two hours – protect skin – C.N.A • Use adult briefs during day – C.N.A • Touch gently and establish eye contact prior

to starting care – ALL • Extensive assist with all ADLs. Dress in

gown – C.N.A.

• Turn side to side in bed every two hours – C.N.A. • Pressure relief mattress on bed and geo mat in geri-

chair - LN • Up in geri-chair every day for 3 hours during lunch.

Reposition every hour – C.N.A. • One to one activities 3X week for sensory stimulation -

AD • Provide country music via radio, TV, or CD - ALL • Family visits daily - ALL • Hi – Pro supplements 2 times a day - LN • Provide pudding as nighttime snack – D and C.N.A.


SAMPLE THREE:

NEED: Behaviors and mood decline impact quality of life: Should have initial start date. Date all additions and deletions. As evidenced by: • Withdrawal from large group entertainment • Resistive to dressing in am • Cries easily • Symptoms of insomnia • Non-verbal indicators of pain such as a frown

and fear of movement • Wrings hands and calls out for daughter

Contributing Factors: • Severe agitated dementia • Recent death of spouse • Room relocation • Strong support from daughter • More upset when tired at the end of the day • Long term relationship with minister • Pain related to osteo and arthritis • Occasional constipation increases agitation • Stiffness in early am • Loves live animals

Note: Merged Mood, Behavior, Psychosocial, Activity, Pain, and Psychoactive Drug Use CAA. OUTCOME/GOAL: Should have measurable time frame. • Resident will be able to dress and get out of bed without being too fearful of pain. • Resident will express relief of chronic pain impacting sleep and ADLs and activity attendance. • Resident will benefit from psychoactive medications without side effects. INTERVENTIONS: Should be dated. • Routine pain medications to decrease pain in

am. - LN • Allow time to move slowly when getting up

in a.m. – C.N.A. • Limited assistance with upper extremities,

dresses slowly, do not tug on arms – C.N.A. • Report any indicators of pain – ALL • Play TV shows that resident enjoys - ALL

• Remind and encourage her to come to group activities that she liked in the past – ALL, AD

• Refer to MH for work-up to r/o depression - LN • Visit 3 times a week to support grieving process - SS • Encourage visits from Minister visits 3 times a week -

ALL • Pet visits monthly - AD • Monitor BMs closely with change in stool softener–LN • Afternoon nap if she will allow – LN • Encourage visits from daughter - ALL • Offer to play books on tape - ALL


CASE STUDY ONE: FALL CAA: Resident has fallen 2 xs in last 2 months. Falls occurred in late afternoon when resident was tired. She attempted to rise from w/c unassisted. She did not use call light or walker. Underlying medical conditions include increased memory problems, inability to balance without walker and extensive assist of one due to generalized weakness and some dizziness. BP’s do not suggest hypotension. No acute problems; i.e., UTI or impaction. Not on any risk drugs, except Lasix. Assistance needed for voiding is a factor. Need to toilet is why she is trying to rise and she refuses or forgets to use call light. Will refer to PT for evaluation and increase ambulation and care plan frequent toileting cycle and non-compliant with using call light and waiting for assistance. NUTRITIONAL STATUS CAA: Triggered because of wt. loss of 6 lbs in last 2 months with decreased appetite. Contributing health conditions are increased memory problems and an episode of diarrhea lasting 4 days 2 wks ago. Functional status, oral status, and vision are all normal. Does not receive any risk meds. She has been more withdrawn since flu episode and says she just doesn’t want to eat much and gets frustrated with our efforts. See Mood CAA. Will discuss with Social Services. Proceed with care planning to increase calories with foods she is willing to eat. MOOD STATE CAA: Triggered: withdrawal from activities, self-isolating. No medical problems except flu episode, and increased memory problems. She has been clearly upset about dependency on staff for care. Daughter states she hates to be waited on. She is aware her memory is declining. No changes in vision or hearing. Not on any risk drugs. No obvious changes in important relationships. Likes roommate and family visits. No outside referral needed at this time. Will care plan to support losses and encourage use of cues to help with memory. Will monitor depression scale and consider outside referral if mood doesn’t improve. ACTIVITIES CAA: Now less involved in activities. Refusing to attend group activities like checkers and bridge. Her concern with memory loss is a factor. She is clearly more withdrawn. Will increase one-to-one visits and encourage playing checkers with me. Will provide more reading material if desired. She states she is too tired now; however, this is likely a mood issue. Will discuss past hobbies of gardening and encourage attending small groups outside in garden. Will proceed with care plan to try to improve mood state and encourage attendance at group activities resident has enjoyed in the past.


CASE STUDY ONE:

NEED: Risk for repeat falls with injury. As evidenced by: • 2 falls in two months in late afternoon • Fell rising from wheelchair

Contributing Factors: • Need to void • Forgets to use call light • Memory loss • Need for independence may refuse to use call light • Urge incontinence • Aware of need to void

Note: Fall CAA with Elimination OUTCOME/GOAL: Should have measurable time frame. • Resident will not have an injury related to fall. INTERVENTIONS: All should be dated. • Refer to PT – LN, PT • Ambulate to all three meals - CNA • 1 person stand by assist - CNA • Encourage to use walker –LN, CNA • Keep walker at bedside and next to

wheelchair at all times – CNA, LN

• Motion alarm in w/c – CNA, LN • Voiding pattern for one week to re-establish pattern

– CNA, LN • Check every hour while awake and every two hours

in bed - CNA • Ambulate to bathroom, do not use bedpan - CNA

Psychosocial well-being/mood decline As evidenced by: • Recent weight loss • Refusing to attend groups – checkers and

bridge • Self-isolating • Expresses sadness and hopelessness

Contributing Factors: • Aware of losing memory • Difficulty playing bridge • Likes independence • Fear of being waited on • Early signs of dementia

Note: Nutrition, Mood, and Activity CAAs OUTCOME/GOAL: Should have measurable time frame. • Resident will identify areas of interest for leisure activities. • Resident will maintain current weight range of ----to----.(fill-in) INTERVENTIONS: All should be dated. • Refer to MH r/o depression and for

medication suggestions - LN • Support grieving process 3 times a week -

SS • Play one-to-one cards one time a week - AD

• Lower functioning game of checkers with other residents – AD

• Encourage outside activities in garden daily – AD • Encourage to play checkers with roommate - AD


CASE STUDY TWO: COGNITIVE CAA: No memory, recent increase in restlessness and disorganized speech. Diagnoses of agitated dementia, diabetes, low fluid intake are key factors. Blood sugar has been fluctuating causing increased symptoms. See MD notes dated 1/1/20XX. Hearing loss creates need for more visual cues as she has problems with both hearing and processing. Symptoms not related to use of Risperdal. Recent use of lap buddy to prevent rising may be a factor re: increased restlessness. See Restraint Use CAA. Plan: proceed with care planning to manage diabetes and behavior symptoms related to cognitive loss. Will discontinue lap buddy; see fall and restraint assessment. FALL CAA: Resident has agitated dementia, diabetes, unaware of limitations, unable to ask for help. Resident is physically restless and slowly slides out of w/c or tries to rise without help. There is no clear trigger prior to rising unassisted except being tired of sitting in the chair. Parkinson’s contributes to sliding from chair. The rise alarm does not give staff enough notice as resident slides out of chair. PT assessed yesterday and recommends wedge no-slip cushion to help with positioning and sliding instead of Lap Buddy. Plan: will discuss with family and resident. See Behavior CAA. BEHAVIOR/PSYCHOTROPIC DRUG CAAs: Agitated dementia: resistant to care, can strike out during care and bite. No episodes of biting this past month. “Calling out for help” can be constant. Antecedents include possible pain, constipation, need to reposition, need to toilet, hunger and bright environment. Repositioning and offering fluid decreases symptoms for 10-15 minutes. She strikes out only when in agitated state. Risperdal given routinely decreased episodes of biting. No side effects noted related directly to drug. Plan: Discuss with Pharmacy to increase pain medications.


CASE STUDY TWO:

NEED: Risk for repeat falls and injury As evidenced by: • Slides out of chair • Tries to rise unassisted out of chair • History of repeat falls

Contributing Factors: • Agitated dementia • Parkinson’s • Inability to bear weight • Fluctuating blood sugars • Pain/discomfort from sitting too long in chair • Need to void • constipation • Psychoactive drug use

Note: Merged Falls and Restraint CAAs if no-slip cushion is a restraint. OUTCOME/GOAL: Should have measurable time frame. • Resident will not experience an injury fall. INTERVENTIONS: All should be dated. • Test using wedge non-slip cushion - LN • Check and reposition every hour in chair –

C.N.A. • Monitor and reposition if sliding down in chair

– ALL

• Voiding pattern for 3 days to determine new toileting plan - LN

• Toilet every 2 hours while awake – CNA • Put down for nap if she agrees daily CNA • Risk alarm in chair –CNA, LN

NEED: Behaviors impacting quality of life: As evidenced by: • Resistant to care • Escalates to striking out and biting • Calling out for help constantly • Use of Risperdal

Contributing Factors: • Agitated dementia/cognitive loss • Parkinson’s • Fluctuating blood sugars • Staff approach • Too many lights on • Pain/discomfort from sitting too long in chair • Need to void • Constipation

Note: Merged Behavior, Psychoactive Drug use, Cognitive CAAs. OUTCOME/GOAL: Should have measurable time frame. • Resident will allow care provision without striking or biting staff. • Resident will benefit from psychoactive drug use without side effect. INTERVENTIONS: All should be dated. • Get eye contact during care – ALL • Monitor for side effects of psychoactive drug

- LN • Task segment when providing care – CNA • Turn on country music to calm during care –

CNA • Turn off overhead light in room, use only

lamp – ALL

• Point out pictures on walls of family members to distract - ALL

• If begins to strike out, stop care - ALL • Responds negatively to tugging on arms - ALL • When calling out for help: Offer food, toilet, and if

needed put to bed - ALL • Reposition in chair every hour, stand and walk a few

steps – CNA


CASE STUDY THREE: Triggered Areas and Care Area Assessment Summary Notes Cognitive: This area triggered due to a BIMs score of 9. He has a diagnosis of dementia, which based on BIMs scores, has progressed over his stay and continued decline is anticipated. He recognizes family and staff, knows he lives in the health center, and is aware of the facility routines. He has a private duty aide eight hours daily. He makes decisions about his care and what he wants to do, but needs reminders and redirection at times. Will continue with care plan to provide re-orientation and consistency in routines and to support the resident’s ability to make decisions as able. Communication: The area was triggered because the resident has a mild hearing loss and uses hearing aids. He has used hearing aids for several years and is independent in placing the hearing aides and removing at night. He has a case in his bedside table. Staff checks with him to ensure he has his hearing aides in and that they are properly stored at night. He does not seem to have a problem with conversation and is able to hear the television at a normal sound level. Will continue with care plan to assist with hearing aides and ensure his hearing is not interfering with conversation. ADL / Incontinence: These areas triggered because the resident needs extensive assistance with all ADL’s and is incontinent of bowel and bladder. He has a diagnosis of Parkinson’s disease. He has not had any significant change in self care ability over the past year. He is incontinent and does not recognize the urge to go. A toileting program was attempted in April and was not effective. He was not willing/able to cooperate with the program and stated he did not want to be bothered. He does not like to be wakened at night for incontinent care and wears a night time brief so sleep will not need to be interrupted. Will continue with care plan to provide ADL and Incontinence Care. Psychosocial: This area triggered due to the residents response of ‘Not very important” when asked about doing favorite activities. His behavior can interfere with socialization as he can become verbally abusive to his wife and caregivers. He frequently talks about moving to Boca to an apartment, which is not realistic. His wife lives at center in Independent Living and visits him routinely. Will continue with care plan to provide divisional activities and encourage appropriate socialization. Behavior: This area triggered due to the presence of verbal and socially inappropriate behaviors which are disruptive to the living environment. This behavior is long standing and is managed with medication. The dose was adjusted in July and is currently at the lowest dose to manage his symptoms. He can be verbally abusive to his wife and verbalizes anger that he does not have control of his money. Will continue with care plan to provide consistency and minimize behavior outbursts.


CASE STUDY THREE:

Problem List: Cognitive / Communication Deficit: Dementia and hearing loss

o Goal: V……… will be able to communicate with caregivers and family. o Interventions: o Wear hearing aide. Places and removes at will o Staff to check for hearing aids daily. o He sometimes takes them out and doesn’t put them away o Staff to assist with locating hearing aids when necessary o Hearing loss is mild. Make sure you have his attention before speaking. o He recognizes his room, staff and family, but may need reminders

Self Care Deficit/Incontinence: related to self-directing care, Parkinson’s o Goal: V…… will assist with care as able, continue to reposition self in bed, and will

agree to being clean and neatly groomed. o Interventions: o He is able to reposition self in bed using the quarter side rails. o Check at night to be sure he is repositioning. o Do not awaken at night for incontinent care. Wears a night time brief. o He is at risk for UTI and needs assistance with peri-care, but may be resistive. o If he refuses peri-care frequently, offer a shower. o Shower every other day (even days) weekly using the shower chair. He enjoys the shower

and will do upper body and wash hair with cueing. o If he is awake, ask if he wants to use the bathroom o He transfers with one assist. Needs help to rise from sitting. Use gait belt o He ambulates only a few steps to transfer o Uses wheel chair for mobility. Can self propel short distances o Staff propel wheelchair long distances. o He needs assistance with toileting. Does not like a bedpan or urinal. o Take to toilet in wc and transfer to the toilet. o Do not leave unassisted in the bathroom.


CASE STUDY THREE: Behavior Outbursts consisting of yelling, hitting, refusing care, anger¸ repetitive verbalization and cursing at his wife.

• Goals: V………. behavior will not interfere with his care and will not disrupt the environment. Behaviors will not escalate to hitting staff or others. Will not have any side effects from psychoactive drug use of ……….

• Interventions: o Maintain consistency in caregivers o Vincent has a care giver during the day that provides diversional activities which

include…….. o Outbursts are triggered by

Not being allowed choices Staff starting care when he is in a mood

o Vincent responds well to A less stimulating environment Going for a ride outside Talking with him about the military

o When he refuses care, ( C-PAP, Incontinent care, ADL Assistance) try again later. o Behaviors include verbally yelling at wife or staff, sudden outburst. Escalating behavior

is Potential for Injury: Falls / Skin Breakdown

Nutrition: Advanced Directives/Discharge Plan: Activities/Psychosocial:

• Goals: V………… will participate in activities in which he has interests. • Interventions:

o Vincent has a strong identification with his professional past. o He has a desk in his room. Provide office supplies and ask him to complete a project. o He enjoys the news. If he is restless, turn on the news on TV or bring a newspaper o His care giver takes him outside o He enjoys music and will sing along. Remind of musical activities. o He enjoys pets, so be sure to include him with pet visits. o Vincent was in the Air Force and enjoys reminiscing about those days with others. o He has pictures and decorations about his life. Ask him to tell you about them.


CHANGE IN CONDITION AND TEMPORARY PROBLEMS

Update permanent care plan to new problem.

1. Update permanent care plan to new problem with goal and interventions. 2. Add to 24-hour report. 3. Pass on in report. 4. QA designee or DON ensures care plan was revised as part of follow-up to 24 hour report or incident

report. If an incident report is made, or an infection report, that triggers a QA check of care plan. 5. Involve other disciplines or initiate protocols. If the problem/need/risk is significant, then the IDT

should review as a group or initiate a SCSA MDS. a. For example, the team may review after a fall or new pressure ulcer, or

recent/new weight loss, new behaviors/moods indicators or new psychoactive drug. Sometimes facilities have weekly or monthly reviews of residents with certain high risk areas.

b. For an isolated medical acute episode that should resolve itself the team approach is not as needed e.g. flu, UTI.

The problem or risk for problem is already care planned: 1. Do not create a new problem if the problem is already on the care plan. If you treat a change as a

new problem the interventions would be in conflict. a. For example, at risk for falls is already on the care plan; under problem

statement, add the fall and date, then review and add or delete interventions with date and initials. If repeat falls, change goal to “prevent injury”.

b. Pressure Ulcer – Same type of update as for falls, but ensure preventive measures are reviewed and revised. Add a new goal to heal, but the preventive goal remains.

c. If problem is related to ADLs, weight loss/hydration, or elimination, update those interventions. o Behaviors and psychoactive drugs for behaviors are care planned together with

updates as needed to new behavior symptoms, mood, or drugs.


TEMPORARY CARE PLAN (for up to 14 days)

Date: Problem # Problem: Outcome: Interventions: 1. 2. 3. 4. 5. 6. 7. 8.







Braden Scale for Predicting Pressure Sore Risk

Resident’s Name: Mr. Jones Nurse Name:

Date of Assessment 1/1

SENSORY PERCEPTION 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR Limited ability to feel pain over most of body

2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness

OR Has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body.

3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.

OR Has some sensor impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

2

Ability to respond meaningfully to pressure-related discomfort

MOISTURE 1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

2. Very Moist Skin is often, but not always moist. Linen must be changed at least once a shift.

3. Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day.

4. Rarely Moist Skin is usually dry; linen only requires changing at routine intervals.

2

Degree to which skin is exposed to moisture

ACTIVITY 1. Bedfast Confined to bed

2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours

2

Degree of physical activity

MOBILITY 1. Completely Immobile Does not make even slight changes in body or extremity position without assistance

2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3. Slightly Limited Makes frequent though slight changes in body or extremity position independently.

4. No Limitation Makes major and frequent changes in position without assistance

2

Ability to change and control body position

NUTRITION 1. Very Poor Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement

OR Is NPO and/or maintained on clear liquids or IV’s for more than 5 days.

2. Probably Inadequate Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.

OR Receives less than optimum amount of liquid diet or tube feeding.

3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered

OR Is on a tube feeding or TPN regimen which probably meets most of nutritional needs.

4. Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

2

Usual food intake pattern

FRICTION AND SHEAR 1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.

2. Potential Problem Moves feebly or requires minimum assistance. During a move skin probably sides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.

Total Score

1

11

Initials

© Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved Scoring: At Risk 15-18 Moderate Risk 13-14 High Risk 10-12 Very High Risk 9 or Below Page 1 of 2


DATE: January 1, 20XX SUMMARY NOTES Resident is at high risk for pressure ulcers with a Braden’s score of 11. Resident is incontinent of urine and uses adult briefs. A toileting plan is in place to decrease incontinent episodes of urine. Toileting schedule is as follows: upon rising, before and after meals and activities, at bedtime, and prn. The resident is usually not incontinent of bowel. She is below her ideal weight, so bony prominences are more a factor to positioning. She needs extensive assist to rise up in bed and to change position so a turning sheet should be used to decrease friction. She sits up in wheel chair during day so a geo mat is needed with position changes hourly in chair and every two hours in bed. A pressure reduction mattress is on the bed. See dietary assessment and plan regarding potential increased weight loss. Fluid needs are also not met without staff pushing fluids during care and meals. Supplements provided between meals and a multivitamin. Does not appear to have any pain other than general discomfort related to immobility. Medical issues include cognitive impairment, post CVA, and mixed incontinence. Family aware of risk and care planning interventions. CARE PLAN EXAMPLE: DATE PROBLEM GOAL DATE INTERVENTIONS DATE Jan.1, 20XX

At Risk for Pressure Ulcers related to: • Underweight • Bony prominences • Immobility in bed • Immobility in chair • Urine incontinence • Risk of shearing and

friction • Low fluid intake • Extensive assist with

ADLs

Will not experience a pressure ulcer. Will have decreased episodes of incontinence during day to 2 times a day.

April 1, 20XX April 1, 20XX

• Dietary interventions per dietary care plan and assessment. • Supplement between meals and MVI daily per order. • Pressure reduction mattress on bed. • Geo mat on chair. • Turn every two hours in bed and one hour in chair. • Toilet upon rising, before and after meals and activities, at

bed time, and prn. • Use adult briefs during the day per resident request. • Use turning sheet. • Do not position on back in bed. • Provide fluids during care and encourage resident to drink

all fluids with meals. • Provide increased fluids during med pass. • Heel protectors in bed. • Use slippers when up.

1/1/20XX 1/1/20XX 1/1/20XX 1/1/20XX 1/1/20XX 1/1/20XX 1/1/20XX 1/1/20XX 1/1/20XX 1/1/20XX 1/1/20XX 1/1/20XX 1/1/20XX


Fall Risk Assessment

Resident’s Name: Jane Smith Assessor: Nurse Nancy PARAMETER SCORE RESIDENT STATUS/CONDITION SCORE

Date

A. Level of Consciousness/ Mental Status

0 ALERT (oriented x 3) OR COMATOSE 2 DISORIENTED X 3 at all times X 4 INTERMITTENT CONFUSION

B. History of Falls (past 3 months)

0 NO FALLS in past 3 months 2 1-2 FALLS in past 3 months 4 3 OR MORE FALLS in past 3 months X

C.

Ambulation/Elimination Status

0 AMBULATORY/CONTINENT 2 CHAIR BOUND-Requires restraints and assist with

elimination

4 AMBULATORY/INCONTINENT X

D.

Vision Status 0 ADEQUATE (with or without glasses) 2 POOR (with or without glasses) X 4 LEGALLY BLIND

E.

Gait/Balance

To assess the resident’s Gait/Balance, have him/her stand on both feet without holding onto anything; walk straight forward; walk through a doorway; and make a turn.

0 Gait/Balance Normal 1 Balance problem while standing X 1 Balance problem while walking X 1 Decreased muscular coordination 1 Change in gait pattern when walking through doorway 1 Jerking or unstable when making turns 1 Requires use of assistive devices (i.e. cane, w/c, walker,

furniture) X

F. Systolic Blood Pressure 0 NO NOTED DROP between lying and standing X 2 Drop LESS THAN 29 mm Hg between lying and standing 4 Drop MORE THAN 20 mm Hg between lying and standing

G.

Medications

Respond below based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics.

0 NONE of these medication taken currently or within last 7 days X 2 TAKES 1-2 of these medications currently and/or within last 7

days

4 TAKES 3-4 of these medications currently and/or within last 7 days

1 If resident has had a change in medications and/or change in dosage in the past 5 days = score 1 additional point

H.

Predisposing Diseases

Respond below based on the following predisposing conditions: Hypotension, Vertigo, CVA, Parkinson’s disease, Loss of limb(s), Seizures, Arthritis, Osteoporosis, Fractures

0 NONE PRESENT X 2 1-2 PRESENT 4 3 OR MORE PRESENT

Total score of 10 or above represents HIGH RISK

TOTAL SCORE 15


DATE SUMMARY NOTES Jan 1, 20XX

Resident’s fall risk assessment revealed that resident is at high risk with score of 15. Resident has Alzheimer’s Disease so she paces frequently and can get very tired. Falls occur in later afternoon as resident is more tired and/or agitated. When agitated the resident speeds up and walks too fast. Resident has a shuffling gait. Resident has fallen sitting on the toilet. Therapy has seen resident in the past with no recommendations. Resident will continue to self ambulate so risk continues. Goal is for continued independent ambulation.

CARE PLAN EXAMPLE: DATE PROBLEM GOAL DATE INTERVENTIONS DATE Jan.1, 20XX Mar 1, 20XX

At risk for repeat fall related injuries related to: • Hx of falls • Poor vision • Need to void • Tiredness • Ambulates

independently • Paces • Agitated, walks too

fast • Non-compliant with

using call light Fell rising from bed no injury

Will not experience a fall related injury through next review.

April 1, 20XX

• Prompted voiding, remind to void every two hours.

• Raised toilet seat. • Contrasted toilet seat cover. • Encourage to lie down when tired in

afternoon. • Wear her thin hard sole shoes during

day. • When agitated, walk with resident

until slows down or sits down. • Add Motion Alarm to bed as she

forgets or refuses to use call light. • Keep slippers on bed or bedside table

so she can reach easier if rising.

1/1/XX 1/1/XX 1/1/XX 1/1/XX 1/1/XX 1/1/XX 3/1/XX 3/1/XX


Potential B&B Retraining: 18- 24:Retraining potential, 10-17: Potential for Habit/Prompted/Scheduled Toileting, 0-9: Poor candidate

Comments

RESIDENT: __________________________________ MED REC#____________

Bowel and Bladder Risk Assessment SCORE 3 2 1 0

Bladder Control Continent or has indwelling catheter

Continent at least 3xday

Continent 1-2x day

Never Continent 2

Bowel Control Continent more than 4xweek or colostomy

Continent 3-4xweek

Continent 1-2x week

Never Continent 3

Can walk to BR or transfer to toilet. Can manage clothes, wipe, urinal

Alone with reasonable speed

Alone but slow Needs assist from one person

Dependent or needs assist from 2 persons or more

1

Mental Status Alert and oriented

Forgetful but can follow prompts

Confused, needs verbal and physical prompts and assistance

Very confused, combative, refuses to cooperate, depressed

1

Mentally aware of toileting needs Yes, always Usually Sometimes Never 2

Condition of skin, genitals, perineal and buttock

No redness Some redness Stage 1-2 pressure Ulcer

Stage 3-4 Pressure Ulcer 3

Predisposing Dis.(DM, CVA, Prostatic Dis, UTIs, Neurogenic Bladder, retention, Terminal

Absent Minor Moderate Severe 2

Medications (diuretics, narcotics, sedatives/hypnotics, antidepressants/antianxiety, antispasmodics, antihistamines, Calcium channel blockers, antiparkinson’s, antipsychotics, neuromuscular)

None Yes, taking one or the meds listed

Yes, taking two or more

Yes, taking three or more 3

Total 17

Date

Signature


Example Care Plan:

ELIMINATION ASSESSMENT SUMMARY Score of 17 indicates potential for improved continence. Appears to have some urgency and calls out for help. Appears to empty bladder based on Bladder Scan results with 40cc residual. Resident requires extensive assistance of one to toilet whether bedpan or toilet secondary to an old CVA. Between voiding, the resident occasionally has stress incontinence. The voiding pattern is predictable at about every two hours upon rising and bedtime. She sleeps thru the night but then needs to void during 6am rounds. She has a regular BM every other day. She drinks fluids well with meals and like fluids during activities. She will take sips of water when encouraged. Type of Incontinence: Urge___ Stress___ Mix _X_ Overflow___ Functional___ Other___ Unknown___ Implement Bladder or Bowel retraining program: Implement Intermittent Catheterization: Implement [] Prompted [] Habit [X] Scheduled toileting training program as the individualization scheduled toileting plan for: X Bladder Bowel OR Prior failed attempts at toileting schedules, implement Check and Change Describe toileting plan: Toilet upon waking up 6am, then check every two hours and immediately if the resident calls out. Toilet prior to nap and bedtime. Do not wake up at night to toilet. The resident will wake up on own. Remove Continue with Foley Catheter Justification: Infection Control in place: X Fluid needs: Encourage fluids during care. X Care Plan Completed Assessment completed by: _Bridget Jones, RN__________ Date: January 1, 20XX__________

Problem Goal Date Interventions Date Jan. 1, 20XX Episodes of Incontinence contributing factors: • Requires ext. assist with

toileting of one person • Urge incontinence • Knows when needs to

void • Stress incontinence • Takes fluids with

encouragement

Will not experience more than 3 episodes of incontinence week.

April 1, 20XX

Encourage fluids during care. Likes room temperature water. When resident calls out, immediately toilet Encourage to use call light. Toilet on bedpan if in bed. When up use toilet. Toilet at 6am upon rising, every two hours, before nap and bedtime, Do not wake up at night to toilet.

1/1/XX 1/1/XX 1/1/XX 1/1/XX 1/1/XX 1/1/XX 1/1/XX 1/5/XX


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