ࡱ> oqn $Rbjbj Sjj Nl****"|*Bffffffff> @ @ @ T T T<$ `fffff`ffufff> f> \" " fZ @N** " " 0" :" ** (Activity Pursuits Altered _______ GOAL: Activities as desired until discharge achieved______________ (Introduce to activities offered_______ (Interview to interests______________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE: __________________________ (ADL Decline__________________ GOAL: Improve ADL skills to achieve Discharge Plan_________________ (Rehab:_________________________ (Grooming:______________________ (Dressing:_______________________(Dining:_________________________ (Ambulation:_____________________ (Siderails:_______________________ (Transfer:________________________ (Toileting:_______________________ DATE:___________________________ (Amputation: BK or AK _____ GOAL: Heal without complications _ _________________________________ (Assess wound site_________________ (Rehab:_________________________ (Nsg:___________________________ (Restorative:______________________ (Dressing: ______________________ (Monitor for depression_____________ (_______________________________ (_______________________________ DATE: __________________________ (Anemia _____________________ GOAL: Minimize complications_____ _________________________________ (Monitor for complicaitons__________ (Monitor nutritional intake__________ (Labs:___________________________ (V.S. each shift:___________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE: __________________________ Resident: ___________________ ( Anticoagulant Therapy________ GOAL: No complications__________ _________________________________ (Monitor for s/s bleeding:___________ (Protect from injury:_______________ (Labs/ Meds as ordrered:____________ (Pro times as ordered:______________ (Safety measures:__________________ (_______________________________ (_______________________________ (_______________________________ DATE: __________________________ (_Behavior Symptom___________ GOAL: Fewer symptoms _________ _________________________________ (Redirect by:_____________________ (Assess Internal Contributors:________ (Assess External Contributors:_______ (R/O Delirium: ___________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (Bladder Training/Foley________ GOAL: Increased continence to achieve Discharge Plan___________ (Encourage fluids_________________ (Foley Cath Care:_________________ (Toilet type:______________________ (Scheduled toileting:_______________ _________________________________ (Bladder training:_________________ (R/O cause of incontinence:_________ (I&O:___________________________ DATE:___________________________ (Bowel Training/Altered Bowel Elimination____________________ GOAL: Establish bowel routine_____ _________________________________ (Dietary referral:__________________ (Meds as ordered:_________________ (Bowel training:___________________ _________________________________ (Monitor elimination pattern, color, consistency, odor___________________ (_______________________________ DATE:___________________________ Room: ________ Adm.#________ (_Cancer_____________________ GOAL: Achieve physical & mental comfort________________________ (Vital signs:______________________ (Hospice:________________________ (Skin status:______________________ (I&O:___________________________ (Weight/Appetite:_________________ (Complications: fatigue, attitude, apprehension, N/V:_________________ (Pain management:________________ DATE:___________________________ (_Cardiac_____________________ GOAL: No complications__________ _________________________________ (Meds______________________ (Assess heart rate, B/P, resps________ (Monitor for edema________________ (Diet restrictions:__________________ (Elevate:_________________________ (O2:____________________________ (Monitor endurance/complications____ (Rehab:_________________________ DATE:___________________________ (_CVA/Stroke Rehab___________ GOAL: Achieve Rehab goals for discharge________________________(Rehab:_________________________ (Grooming:______________________ (Dressing:_______________________ (Dining:_________________________ (Transfer:________________________ (Ambulation:_____________________ (Toileting:_______________________ (Siderails:_______________________ DATE:___________________________ (_Cognitive Decline____________ GOAL: Establish daily routine______ _________________________________ (Task segments___________________ (Cue as needed____________________ (Reality orientation PRN____________ (Offer choices____________________ (Visual cues:_____________________ (Speech therapy:__________________ (_______________________________ (_______________________________ DATE:___________________________ Dr. ________________________ INITIAL CARE PLAN (_Communications Decline______ GOAL: Increase ability to communicate___________________ (Communication techniques:________ (Speech Therapy referral:___________ (Evaluate hearing loss:_____________ (Check ears for wax:_______________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Dehydration/Risk of__________ GOAL: Consume adequate fluids___ _________________________________ (I&O___________________________ (Determine likes/dislikes:___________ (Offer fluids between meals:_________ (Monitor for dehydration:___________ (Specific Gravity__________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Delirium Present_____________ GOAL: Resolve Acute Condition____ _________________________________ (Meds:__________________________ (R/O for acute illness/Labs:__________ (Orient PRN______________________ (Assess for pain/constipation/UTI_____ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Dental Problems_____________ GOAL: Resolve_________________ _________________________________ ( Meds/TX's:_____________________ (Monitor appetite:_________________ (Assess oral cavity:________________ (Evaluate need for dental exam:______ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ Resident:___________________ (_Diabetic Alert________________ GOAL: No complications__________ _________________________________ (Meds:__________________________ (Diet:___________________________ (Monitor S/S Hypo/hyperglycemia____ (Accuchecks as ordered:____________ (Labs as ordered:__________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Discharge Planning__________ GOAL: Achieve discharge as planned ___________________________ (Interview Resident________________ (Interview Family_________________ (Arrange Post-discharge____________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Fall/Safety Risk______________ GOAL: No injury falls_____________ _________________________________ (Assess for contributors: Bps standing, sitting, pain, need to void, meds gait____ (Encourage to use call light__________ (PT referral______________________ (Instruct on safety measures_________ (Adaptive Device (OT)_____________ (_______________________________ (_______________________________ DATE:___________________________ (_Feeding Tube_______________ GOAL: No complications__________ _________________________________ (I&O___________________________ (T.F. Order______________________ (Speech Therapy referral____________ (Assess for placement:______________ (Labs:___________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ Room:_________ Adm.#_______ (_Fracture/Fractured Hip________ GOAL: No complications__________ _________________________________ (Cast:___________________________ (Positioning:_____________________ (Pain:___________________________ (Safety Procedures:________________ (Rehab:_________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_G.I. Disorder________________ GOAL: Decreased symptoms______ _________________________________ (Nutrition:_______________________ (Meds:__________________________ (Bowel sounds:___________________ (Monitor Bms for consistency, color, odor_____________________________ (I&O___________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Infection Alert_______________ GOAL: Resolve infection__________ _________________________________ (Monitor for S.S. for infections_______ (Tx:____________________________ (Wound status and progress_________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_I.V. Therapy_________________ GOAL: No complications__________ _________________________________ (I&O___________________________ (I.V. orders:_____________________ (_______________________________ (Weigh every:____________________ (Monitor for complications__________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ INITIAL CARE PLAN (_Mood Symptoms_____________ GOAL: Decreased symptoms______ _________________________________ (Activities:-______________________ (Depression scale:_________________ (Meds:__________________________ (Likes to:________________________ (S.S. 1:1_________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Nausea and Vomiting_________ GOAL: Resolve_________________ _________________________________ (Intake:_________________________ (Monitor for dehydration:___________ (Document frequency, amount, color/consistency of emesis___________ (Meds:__________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Nutrition____________________ GOAL: Achieve/maintain weight of:_ _________________________________ (Intake/Appetite___________________ (Diet:___________________________ (Weigh q:________________________ (S.T. Ref.________________________ (Determine likes/dislikes____________ _________________________________ (Supplements_____________________ (_______________________________ DATE:___________________________ (_Ostomy_____________________ GOAL: Participate in ostomy care___ _________________________________ (Ostomy protocol__________________ (Teach self-care___________________ (Monitor for complications__________ (Monitor for infections at ostomy site__ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ Resident:___________________ (_Pain_______________________ GOAL: Experience less pain_______ _________________________________ (Meds:__________________________ _________________________________ (Non-drug interventions:____________ _________________________________ (Monitor pain q shift_______________ (Assess pain tolerance______________ (_______________________________ (_______________________________ DATE:___________________________ (_Physical Restraints___________ GOAL: Experience no complications_ _________________________________ (Assess for alternatives_____________ (Restraint reduction initiated:________ (Restraint order:__________________ (Alternatives:_____________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Pressure Sore/Skin at Risk____ GOAL: Prevent/heal pressure sores_ _________________________________ (Tx:____________________________ (Preventive:______________________ _________________________________ (Position:________________________ _________________________________ (Supplements:____________________ (Wound team referral:______________ (_______________________________ DATE:___________________________ (_Psychosocial Well-being______ GOAL: Express satisfaction________ _________________________________ (Orient to facility:_________________ (Activities:_______________________ (1:1 by Social Service______________ (Customary routine:________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ Room:_________ Adm.#_______ (_Psychotropic Drug Use_______ GOAL: Benefit without side effects__ _________________________________ (Monitor for side effects:____________ (Assess for non-drug interventions____ (Trial reduction:__________________ (Monitor Behavior or Mood Symptoms (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Renal Failure with Dialysis____ GOAL: Experience no complications_ _________________________________ (Weigh:_________________________ (Assess for S/S infection, hypovolemia (Observe for S/S bleeding___________ (Dialysis schedule_________________ (No BP in shunt arm_______________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Respiratory/Tracheostomy____ GOAL: Maintain patent airway______ _________________________________ (Lung sounds/cough sounds/Resp.____ (O2_____________________________ (Suction:________________________ (Trach care:______________________ (Meds:__________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Seizure Disorder_____________ GOAL: Will not injure self or others__ _________________________________ (Seizure precautions_______________ (Meds___________________________ (Side rails:_______________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ Dr._______________________ INITIAL CARE PLAN (_Skin Condition (non-decub)___ GOAL: Resolve_________________ _________________________________ (Treatment:______________________ (Monitor for infection:______________ (Preventive:______________________ (Positioning:_____________________ (_______________________________ (_______________________________ (_______________________________ (_______________________________ DATE:___________________________ (_Terminal Care_______________ GOAL: Death with dignity_________ _________________________________ (Meds:__________________________ (1:1_____________________________ (Hospice_________________________ (Pain Manaagement:_______________ (Comfort measures:________________ (Treatment:______________________ (_______________________________ (_______________________________ DATE:___________________________ (_TPN Therapy________________ GOAL: No complications__________ _________________________________ (Monitor for infection & complications (Line type:_______________________ (Flow rate:_______________________ (TX protocol:_____________________ (Monitor nutriton:_________________ (I&O___________________________ (_______________________________ (_______________________________ DATE:___________________________ (_URI/Pulmonary Disease_______ GOAL: Resolve_________________ _________________________________ (Lung sounds/resp:________________ (Cough status:____________________ (Level of consciousness:____________ (Tx:____________________________ (Suction:________________________ (O2_____________________________ (_______________________________ (_______________________________ DATE:___________________________ Resident:___________________ (_UTI Alert____________________ GOAL: Resolve_________________ _________________________________ (I&O:___________________________ (Status of continence:______________ (Meds / side effects:________________ (Urine color, frequency, burning______ (_______________________________ (_______________________________ 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