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Wooster Community Hospital Community Care NetworkDisease Specific Plan of CareDisease Specific Plan of CareDisease DateRespCommentsDiabetesGoal: To decrease HA1C from _____ to _____ in 3 monthsReview Diabetes Education BookletReview signs and symptoms of hyper/hypoglycemiaReview requirements for blood sugar monitoringHave patient demonstrate how they take their blood sugarsDiscuss blood sugar times and numbersSet BS number goalsProvide log and instructions on BS logsRequest date of last HA1cTeach relationship between HA1c and long term complicationsCheck last eye, foot, dental appointmentsMake appointments and monitor visitInstruct on action and side effects of insulinRecord name and most recent visit to PC or endocrinologists for diabetic follow-upRefer to Diabetic Education programUse Teach Back method for any educationComplete diabetic foot screeningInstruct on good skin/foot care and monitor patient for the presence of skin lesions on the lower extremitiesInstruct on long-term effects of non-compliance/complications.Instruct on diabetic ketoacidosisInstruct on diet and food diary.Instruct on insulin admin and needle disposal.Disease Specific Plan of CareDisease DateRespCommentsCOPD/ Asthma/ PneumoniaCOPD Goal:Asthma Goal: Pneumonia Goal: Patient has O2 and nebulizer equipmentReview booklet on COPDTeach behavior to improve breathing and educate regarding precipitating factors of exacerbationsAssess most recent pulmonary function study/ request from providerComplete pulmonary follow up post dischargeAssess/instruct on home O2 safety measuresAsses/instruct on measures to breath/coughAssess measures to prevent complicationsAsses/instruct on importance of rest periodsInstruct on disease of ________Instruct on relaxation/ panic control techniqueInstruct on ROM exercisesInstruct on energy-saving techniquesPlace Telehealth Unit vital signs and PO2Instruct on infection control measuresInstruct on need to monitor temperatureInstruct on importance of restEncourage use of incentive spirometerInstruct on what is pneumoniaInstruct on s/s to report to the CCNInstruct on when to call CCN/ when to call 911Instruct on coughing and deep breathingAssess dehydration understandingInstruct on s/s of dehydration and reportingOther ____________________Disease Specific Plan of CareDisease DateRespCommentsHeart FailureChest PainGoal:Telehealth Unit for vital sign measurementProvide log for tracking vital signs and weightCoordinate receipt of equipmentInstruct on weight measurement and meaningReview signs/symptoms/causes of HFTeach when to call physician/ when to call 911Ensure follow-up with PCPTeach lifestyle behaviors to improve blood pressureEnsure LIPID panel and PT/INR are being doneRecognizes signs of foot edemaStates early s/s of CHF to reportRecords weight, symptomsStates complications of CHFUnderstands medicationsUnderstands diet/ reason for decrease saltDemonstrates knowledge of O2 useReview CHF booklet/ ensure understandingOther ____________________Disease Specific Plan of CareDisease DateRespCommentsHypertensionGoal:Primary/ Secondary Stroke PreventionReview hypertension bookletPlace Telehealth unit in homeInstruct on tracking vital signsReview weight monitoringInstruct on tracking vital signsReview weight monitoringInstruct on proper use and recording of vital signsReview signs/symptoms of hyper/hypotension/causes and associated actionsFollow-up for hypertension with PCPTeach behaviors that improve blood pressureCheck on recent lipid panel/PT/INRReport BP as indicated:Systolic range _______________Diastolic range ______________Pulse range ________________Instruct on when to call CCN or 911Instruct on effects of smoking on the heartInstruct on nutrition/diet: low fat/NA/ cholReferral for nutritional counseling, if neededOther _____________________Review signs & symptoms of stroke – FACEReview action steps if stroke symptoms occur (911)Disease Specific Plan of CareDisease DateRespCommentsChronic PainGoal:Complete pain assessmentReview pain treatment modalities patient has used in pastAssess pain triggers and onsetIndentify causes of the painEducate regarding pain relieving techniquesEducate on s/s to report to CCN and when to go to EDReferral for pain management with specialistsReview pain medications, use, benefits, need for complianceReview pain pathophysiologyOther_____________________Disease Specific Plan of CareDisease DateRespCommentsEnd Stage Renal DiseaseGoal:Teach fluid/electrolyte balance and proper nutritionRefer to dietitian, if neededMonitor compliance with getting BUN/creat test doneTeach regarding complications of hemo/ peritoneal dialysisEstablish and record dialysis scheduleSpecialty follow-up to nephrologyOther _____________________References:Camden coalition of healthcare providers. (2014). Care management forms. Retrieved April / 10, 2014, Retrieved from ................
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