PATIENT: Admission to hospice: Allergies: ID No: Physician: Diagnosis: Discipline: Names: Frequency of visits: Nursing Dianne Michaud, RN BSN Anita Droll, RN Donna Lee Fisher, RN 1-3 x week & PRN, Rita Wollenberg, RN Debra Hedke, RN BSN Kirstin Wernecke, LPN 4-6 x week & PRN, or Deb Martin, RN BSN Sherry Wiese, RN Christine Smith, RN MS 5-7 x week & PRN Paula Cherney, RN Denise Beeson, RN Dawn Thorn, LMSW Donna Coufal, LBSW Katrina Jones, LBSW Social work Marilyn Dressman, LBSW Stephanie Garrison, LBSW Joyce Nelson, LMSW 2-4 x month and PRN Pastoral Care Rev. Susan Sawyer 1 x 3 month & PRN Volunteers Charlotte Topel and Deb Pyle, Volunteer Coordinators Medical Director John Kelley, MD 1. ALTERATION IN COMFORT Goal: Patient will demonstrate reduction of discomfort at least to the point of tolerance. Caregiver will understand the contribution to anxiety to pain and will administer anxiolytics effectively. Patient and caregiver will identify 0-10 pain scale. I = Initiated A. Discomfort a/o pain 1. Evaluate pain on scale of 0-5 R = Resolved B. Rest a/o sleep 2. Teach administering pain meds ATC P= Potential C. Anxiety 3. Evaluate pain medication for effectiveness E. Other: 4. Encourage frequent rest periods 5. Teach sign/symptom of anxiety 6. Teach proper administration of medications 1. Evaluation: 2. ALTERATION IN PATIENT / FAMILY COPING Goal: Patient/Family will address and resolve issues surrounding terminal illness. I = Initiated A. Accepting terminal diagnosis 1. Discuss patient/family feelings regarding illness R = Resolved B. Understanding stages of grief 2. Explore and employ coping mechanism P = Potential C. Making plans for last stages of life & after death 3. Other emotional support: D. Other: 4. Present printed information 5. Provide good listening & assist with plans PRN 6. Social assessment 7. Ongoing team meeting interaction 2. Evaluation: Page 1 of 7
3. ALTERATION IN COGNITIVE / PERCEPTUAL PATTERN Goal: Family understanding of changes in communication, cognition and increased knowledge of how to deal with changes. I =Initiated A. Cognitive alteration 1. Explain pathophysiology of altered status R = Resolved B. Communication alteration 2. Allow more time for patient to respond when P = Potential C. Confusion / disorientation conversing D. Sensory alteration 3. Anticipate needs to ensure patient safety E. Other: 3. Evaluation: 4. ALTERED NUTRITION A/O FLUID STATUS Goal: Patient will maintain highest degree of nutrition/fluid balance possible. I = Initiated A. Dehydration R. Dysphasia 1. Explain pathophysiology of altered status R = Resolved B. Ascites G. Anorexia 2. Encourage smaller, more frequent feedings P = Potential C. Edema H. Decreased intake 3. Encourage use of supplements D. Obesity I. Nausea 4. Teach patient/family about antiemetics when ordered E. Vomiting J. Other 5. Evaluate hydration status and discuss alternatives 4. Evaluation: 5. ALTERATION IN BOWEL A/O URINARY ELIMINATION Goal: Bowel a/o bladder emptied adequately and complication prevented/minimized. I = Initiated A. Constipation E. Dysuria 1. Explain pathophysiology of altered status R = Resolved B. Incontinence F. Retention 2. Encourage stool softeners unless pt. having diarrhea P = Potential C. Diarrhea G. Foley catheter 3. Monitor for signs and symptoms of UTI D. Frequency H. Other: 4. Teach Foley catheter care 5. Evaluation: 6. IMPAIRED SKIN INTEGRITY Goal: Skin lesions minimized and complications prevented. I = Initiated A. Wounds R. Venous access 1. Assess skin integrity R = Resolved B. Lesions device 2. Encourage frequent turning as much as possible P = Potential C. Infections G. Other 3. Treatment D. Inflammations 4. Teach family E. Dermal ulcers 5. Assess signs and symptoms of infection 6. Evaluation: Revised 02/21/05 csc Page 2 of 7
7. INEFFECTIVE AIRWAY CLEARANCE A/O IMPAIRED GAS EXCHANGE Goal: Symptoms of respiratory distress will be decreased. I = Initiated A. Dyspnea D. Anxiety 1. Assess lung sounds R = Resolved B. Cough E. Sleep disturbance 2. Teach family to elevate head of the bed P = Potential C. Orthopnea F. Other 3. Teach family regarding oxygen administration 7. Evaluation: 8. IMPAIRED MOBILITY Goal: Conservation of energy for desired activities and secured safe environment. I = Initiated A. Weakness 1. Assess specific functional limitation/level of R = Resolved B. Vertigo impairment P = Potential C. Impairment of dexterity/activity/coordination 2. Assess safety needs, skin condition D. Alteration in ability to perform ADL s/personal care 3. Teach positioning, turning, skin care, and personal care 4. Teach use of assistive devices (e.g. cane, etc.) 8. Evaluation: 9. ALTERATION IN CARDIAC OUTPUT Goal: Patient will maintain highest degree of cardiac output as allowed by terminal illness. I = Initiated A. Altered myocardial contractility/intotropic changes 1. Auscultate apical pulse assessing heart rate/ R = Resolved B. Alteration in rate, rhythm, electrical conduction rhythm P = Potential C. Structural changes (e.g. valvular defects, 2. Monitor blood pressure ventricular aneurysm, etc.) 3. Inspect skin for pallor, cyanosis, diaphoresis D. Edema 4. Monitor urine output and color 5. Encourage rest periods 6. Teach proper administration of medications as ordered by physician 7. Explain pathophysiology of altered status 9. Evaluation: 10. OTHER: Goal: I = Initiated R = Resolved P = Potential 10. Evaluation: anurse signature adate Revised 02/21/05 csc Page 3 of 7
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11. PSYCHOSOCIAL DISTRESS RELATED TO LOSS Goal:. Patient/family address and resolve issues surrounding psychosocial distress. I = Initiated A. Loss of home/environment 1. Social Worker will provide counseling to R = Resolved B. Loss of cognitive abilities resolve identified issues P = Potential C. Loss of family/friends 2. Social Worker will make referrals to E. Recent diagnosis and terminal prognosis appropriate community resources F. Other: 11. Evaluation: 12. PSYCHOSOCIAL DISTRESS RELATED TO FINANCIALS I = Initiated A. Financials 1. Social Worker will provide counseling to R = Resolved B. SRS referral resolve identified issues P = Potential C. Disability referral 2. Social Worker will make referrals to D. Loss of cognitive abilities appropriate community resources E. Other: 12. Evaluation: 13. PSYCHOSOCIAL DISTRESS RELATED TO ADVANCED DIRECTIVES I = Initiated A. Living Will 1. Social Worker will provide counseling to R = Resolved B. Durable Power of Attorney for health care decision resolve identified issues P = Potential C. DNR 2. Social Worker will make referrals to D. Other: appropriate community resources 13. Evaluation: 14. PSYCHOSOCIAL DISTRESS RELATED TO RESOURCE LINKAGE I = Initiated A. Meals on Wheels E. Life Line 1. Social Worker will provide counseling to R = Resolved B. Homemaking F. Legal assistance resolve identified issues P = Potential C. Private duty care G. Transportation 2. Social Worker will make referrals to D. Nursing home placement H. Other: appropriate community resources 14. Evaluation: Revised 02/21/05 csc Page 5 of 7
15. PSYCHOSOCIAL DISTRESS RELATED TO CAREGIVER ISSUES I = Initiated A. No caregiver in the F. Complicated family 1. Social Worker will provide counseling to R = Resolved home dynamics resolve identified issues P = Potential B. Hired caregiver(s) G. Conflict/estrangement 2. Social Worker will make referrals to C. Abuse/neglect issues H. Children in the home appropriate community resources D. Education materials I. Substance abuse issues required J. Other: 15. Evaluation: 16. PSYCHOSOCIAL DISTRESS RELATED TO: I = Initiated A. Psychosocial diagnosis D. Depression 1. Social Worker will provide counseling to R = Resolved B. Suicidal/homicidal E. Denial resolve identified issues P = Potential ideation F. Other 2. Social Worker will make referrals to C. Substance abuse appropriate community resources 16. Evaluation: 17. SPIRITUAL DISTRESS RELATED TO: Goal: Patient/family address and resolve spiritual issues. LEGEND HOSPICE CHAPLAIN LEGEND PLANS LEGEND I = Initiated A. Shame and guilt E. Funeral 1. Hospice Chaplain will provide spiritual R = Resolved B. Fear F. Spiritual support counseling and support P = Potential C. Spiritual estrangement G. Other: D. Family concern 17. Evaluation: 18. SOCIAL/ENVIRONMENTAL SUPPORT RELATED TO: Goal: To meet identified volunteer needs. LEGEND VOLUNTEER LEGEND PLANS LEGEND I = Initiated A. Caregiver relief D. Transportation 1. Social worker will address safety issues and R = Resolved B. Visitation E. Emergency storm plan review storm evacuation plans P = Potential C. Errands F. Home safety 2. Volunteer matched to provide support services 18. Evaluation: asocial Worker signature adate Revised 02/21/05 csc Page 6 of 7
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