ADMISSION CARE PLAN. Orient PRN to person, place, & time

Transcription

1 ADMISSION DATE: CODE STATUS: ADMISSION CARE PLAN ADMISSION DIAGNOSIS: 1. DELIRIUM 2. COGNITIVE LOSS Resident will be as alert and oriented as possible Resident will be as alert and oriented as comfortable Orient PRN Assess for pain Assess for constipation R/O acute illness Minimize distractions Orient PRN to person, place, & time Introduce self Approach in calm manner Explain what you intend to do while providing care Anticipate needs and observe for non-verbal cues 3. VISUAL FUNCTION 4. COMMUNICATION Resident will have optimal visual ability Goal Resident will be able to communicate his/her wants, needs Visual Aides: Keep glasses clean Encourage resident to wear glasses/have readily available Adequate lighting in room Orient to objects in room Eye drops as ordered If severe loss, encourage activities not requiring visual acuity Hearing aides: ST referral Do not pretend to understand, request clarification when needed Speak directly to resident in clear voice facing him/her Ask simple yes/no questions and allow adequate time to respond 5. ADL FUNCTIONAL / REHAB POTENTIAL 6. B/B INCONTINENCE / CATHETER CARE Resident will achieve maximum functional mobility Resident will establish an individual bowel/bladder routine Consult PT, OT, ST as needed Bathing/Hygiene amount of assist: Dressing/Grooming amount of assist: Eating amount of assist: Toileting amount of assist: Ambulation/Transferring amount of assist: ROM: Resident care as per facility protocol Toileting how often: Check for incontinence how often: Catheter care per policy (attach policy) Intake & Output Bladder training Bowel protocol as ordered Keep call light in easy reach Briefs, depends, or pantiliners when OOB

2 7. PSYCHOSOCIAL WELL-BEING 8. MOOD STATE Resident will express/exhibit satisfaction Resident will express/exhibit satisfaction Orient to facility Customary routines adhered to: Allow to express feelings Listen carefully and be non-judgmental Keep topics of conversation light and cheerful Allow to participate in daily care and decision/goal making Introduce to other residents and encourage socialization Social Services to visit 1:1 as needed Likes to: Assess, monitor, and document mood Encourage group activities Consult Pastoral care PRN Be reassuring and listen to concerns 9. BEHAVIORAL SYMPTOMS 10. ACTIVITIES Resident will have fewer episodes of Resident will attend/participate in 1 activity per week Redirect resident as needed Convey acceptance of res. during periods of inappropriate behavior Always ask for help if resident becomes abusive/resistive Keep environment calm and relaxed Remove from public area when behavior is unacceptable Encourage diversional activities Consult family/friends of interest prior to admission Introduce to activities offered Evaluate time awake and readiness for activity 11. FALLS / SAFETY RISK / ELOPEMENT RISK 12. NUTRITIONAL STATUS / DIET Resident will remain free of injuries and falls Maintain stable weight Keep call bell in reach Orthostatic hypotension precautions Enc. Use of call light If unable to use call light, NA will assess resident q30-60 min Instruct resident on safety measures PT referral Mobility alarm/wander alarm (circle one if needed) Assess resident's footwear for proper fit and non-skid soles Diet as ordered: Fluid consistency: Weigh every Supplements: Monitor meal %'s Determine likes/dislikes Report problems to charge nurse, i.e.: choking, difficulty chewing

3 13. FEEDING TUBES 14. DEHYDRATION / FLUID MAINTENANCE Resident will experience no complications Resident will consume adequate fluids NPO Enteral feeding order: Monitor tolerance of feelings Elevate HOB 30 degrees I&O q shift Observe peg tube/g-tube site for S/S of infection/irritation Oral hygiene every Encourage fluids Monitor for S/S of dehydration Diuretic use: Labs as ordered Hydration protocol Monitor for edema, dyspnea 15. ORAL / DENTAL STATUS 16. PRESSURE SORES / SKIN CARE Maintain oral hygiene/status Prevent/heal pressure sores and skin breakdown Dentures: Oral care BID Assess oral cavity Evaluate need for dental exam Mark dentures for personal identification TX: Follow facility skin care protocol Turn every 2 hours and PRN Preventative measures: Repot to charge nurse any redness or skin breakdown immediately 17. PSYCHOTROPIC DRUG USE 18. RESTRAINTS Benefit without side effects Monitor target behaviors per psychotropic flowsheet Monitor for side effects per psychotropic flowsheet Gradual dose reduction Refer to Social Services as needed Type/reason: Assess for alternatives Restraint reduction initiated Lesser restrictive device used first Release/reposition every 2 hours Keep call light and personal articles within easy reach Alternatives:

4 19. HIP FRACTURE 20. UTI Resident will have maximum functional mobility Resolve Follow hip fracture protocol (attach) Dr. orders for positioning WBS: Monitor pain Rehab orders/recommendations: Monitor every shift on UTI flowsheet I&O Antibiotics as ordered Encourage fluids Monitor urine color, frequency, burning 21. URI / PNEUMONIA 22. ANTICOAGULANT Resolve CXR as ordered Monitor every shift on URI sheet Antibiotics as ordered Lung sounds O2: Respiratory care: Monitor labs as ordered Monitor S/S of bleeding Protect from injury 23. PAIN 24. INFECTION ALERT RResident will be as comfortable as possible Resolve infection Monitor pain Non-drug interventions: Administer pain medications as ordered Establish causative factors and ways to alleviate them Type: Monitor for S/S of infection VS every shift Monitor wound/lesion status and progress Infection control per protocol Isolation:

5 25. CARDIAC 26. DIABETES Assess HR/BP/Resp Oxygen therapy/o2 sats Diet restrictions Elevate HOB degrees Monitor endurance/complications Monitor edema Monitor for S/SS of heart failure, Dyspnea Blood sugar checked every Diet as ordered Observe for S/S of hypo/hyperglycemia Nail care Labs as ordered 27. TERMINAL CARE 28 Death with Dignity Hospice consult Visit one on one Pain management Comfort measures Advance directives 29 30