CARE PLAN - Amazon S3



CARE PLAN

GOALS AND ACTIONS

ANOREXIA

Goal:

▪ Make dietary changes for long term health.

▪ Achieve optimal physical and mental wellbeing.

Action:

▪ Ongoing monitoring/review of diet.

▪ Counselling, support and disease management.

▪ Monitor haematology and blood pressure.

ALZHEIMER’S DISEASE

Goal:

▪ Achieve optimal physical and mental wellbeing

Action:

▪ Regular physical and stimulating leisure activities.

▪ Medications as prescribed.

▪ Counselling and support.

▪ Contact with Alzheimer’s Association of Victoria for information and support services. Contact with Occupational Therapist for assistance regarding home aids etc.

Monitor:

▪ Observe clinical features

▪ Review of self management

ASTHMA

Goal:

▪ Confirm diagnosis

▪ Action – spirometry

▪ Assessment of symptom control

▪ Action – reviews of 2 week diary of symptoms and peak flows.

▪ Manage medications to achieve best lung function

▪ Action – Review asthma medication and technique of puffers

▪ To identify and minimize environmental triggers and allergens

▪ Action – Skin prick allergy testing

Medication

Management

Goal

▪ Prevention and relief of symptoms, patient education

Action

▪ Regular assessments and ensure patient understanding. Regular prescriptions.

Education

Goal

▪ To promote better self-management of asthma through greater understanding of the disease.

▪ Action – asthma education addressing: cause of asthma, social and lifestyle factors, triggers and avoidance, inhaler techniques, emergency action plan, differentiate reliever and preventer medication (Provider responsible is GP and Asthma Educator)

Goal

Action

▪ Patient to self-administer and understand the effects of medications

▪ Differentiate reliever and prevention medication

▪ Teach and review device technique/care

Specialist

Assessment

Goal

▪ To identify changes in medical condition and change treatment accordingly

Action

▪ To assess annually (Provider responsible is respiratory specialist)

Goals of Patient – keep a 2 week diary of symptoms and peak flows

- learn about asthma and triggers

- how to recognize deterioration

- understand what actions to take when asthma worsens

- learn about asthma medications and delivery systems

- regular review with GP when free of acute exacerbations

- early appointment with GP for treatment of exacerbations

BLADDER

INCONTINENCE

Goal

▪ To achieve and manage adequate bladder control/bowel pattern

Action

▪ Encourage 9x drinks per day

▪ Limit drinks 2 hours pre bed time

▪ Pelvic Muscle exercises

▪ Continence pads/aids

STRESS INCONTINENCE

Goal

▪ To maximize urinary continence, provision of comfort

Action

▪ Education re pelvic floor exercises, provision of continence aids, possible referral to Women’s Physio Practice

URETHRAL STRICTURE

Goal

▪ To maintain optimal urine flow

Action

▪ Regular review with urologist regarding internal urethrotomy and need for dilatations

URINARY TRACT INFECTION

Goal

▪ Prevent recurring infection

Action

▪ Adequate fluid intake, education on UTI prevention

▪ Medication as required

VOIDING DIFFICULTIES

Goal

▪ To ensure urine flow rate returns to optimal level

Action

▪ Review with urologist for repeat flow rate and bladder scan

BOWEL

COELIAC DISEASE

Goal (Dietary)

▪ Make dietary changes for long-term health

Action

▪ Gluten free diet. Reduce fat, increase fibre and spread carbohydrates throughout the day. Regular exercise

COLOSTOMY – AP RESECTION

Goal

▪ Regain improved function in and perform activities of daily living with minimal or no restrictions

▪ Management of colostomy

Action

▪ Assess social circumstances, home environment and nursing needs to provide short-term interventions in order to remain living at home

▪ Decrease the risk of future admissions to hospital

IRRITABLE BOWEL

Goal

▪ To achieve/manage an adequate bowel pattern. To identify and minimize triggers

Action

▪ Regular reviews with gastroenterologist. Patient to demonstrate an understanding of the condition and its treatment by adhering to a prescribed regime, including diet, exercise and medications

DIVERTICULITIS

Goal

▪ Regular assessment of bowel condition

▪ Bowel to be free of inflammation and ? obstruction

Action

▪ Regular reviews with gastroenterologist when

▪ When diverticulitis apparent rest at home suggested with diet modification; review with gastroenterologist as required.

CARDIAC

ANGINA

Goal

▪ Promote self-management through greater understanding of the condition

Action

▪ If further episodes of chest pain – suggest further testing and review of medications

▪ Use of nitro lingual spray to relieve angina, monitor effectiveness

▪ If chest pain not relieved in 10-15min _____ ambulance should be called

▪ _____ tablets – check expiry date

AORTIC STENOSIS

ATRIAL FIBRILLATION

Goal

▪ To identify changes in cardiac condition and change treatment accordingly

▪ Cardiac status to remain well controlled and asymptomatic

▪ To promote better self management, through greater understanding of the condition

Action

▪ Regular blood tests, medications reviews and blood pressure monitoring

▪ Attend yearly reviews

▪ Monitor cardiac status

▪ Regular reviews with cardiologist

▪ Reinforce healthy eating and lifestyle patterns.

▪ Discourage smoking

HYPERCHOLESTEROLAEMIA

Goal

▪ Reduce risks associated with hypercholesterolemia

▪ Improve serum cholesterol profiles, achieve target cholesterol of 4.0

Action

▪ Regular serum cholesterol profiles, review medications, diet modification

HYPERTENSION

Goal

▪ Maintain blood pressure within acceptable parameters/maintain stable blood pressure

▪ Improve blood pressure control

▪ To control and stabilize blood pressure

▪ Assess and record blood pressure each visit to assess for hypo/hypertension and monitor the effectiveness of anti-hypertensive therapy

Action

▪ Regular blood pressure monitoring, review anti-hypertensives

▪ Annual ECG monitoring

▪ Six weekly review of blood pressure medications

▪ Patient education of risk factors

MEDICATIONS

Goal

▪ Increase knowledge of medications and ensure correct use

▪ Renewal of scripts and monitor medication compliance

▪ Monitor medication to maintain general cardio protective therapy

▪ Cardiovascular prophylaxis

Actions

▪ Dispense medications as prescribed

▪ Continued patient education regarding scripts

▪ Annual medication review to ensure compatibility of medications and assess medication compliance

CANCER

CANCER – BLADDER

Goal

▪ Early detection (of recurrence)

Action

▪ Regular Cystoscopy

CANCER – BREAST

Goal

▪ Early detection and management of changes in breast tissue

Action

▪ Self examination of breasts monthly; regular clinical breast checks. If lump consult doctor without delay, 2 yearly mammogram due

▪ Mammogram 2 yearly until 70, and then only on request if last two mammograms clear

CANCER – SKIN

Goal

▪ Prevention and early detection of skin cancer

▪ Management and early identifications of skin lesions

Action

▪ Ongoing surveillance and Sunsmart measures

CANCER – PROSTATE

Goal

▪ Ongoing surveillance and subsequent treatment of any changes in prostate condition

Action

▪ Regular review with urologist. Regular PSA levels

PAP SMEAR

Goal

▪ Early detection and management of changes in cervical tissue

Action

▪ 2 yearly Pap Smear test until 70, and then not if last two clear

METASTESES

Goal

▪ Ongoing surveillance and subsequent treatment

Action

▪ Regular review with specialists and subsequent treatment as required

▪ Support from co-ordinated team of health professionals

CHOLELITHIASIS

Goal

▪ To monitor signs and symptoms caused by gallstones

Action

▪ Regular reviews, if symptoms appear – active therapy may be warranted

CHRONIC FATIGUE

Goal

▪ Perform activities of daily living with minimal or no restrictions

Action

▪ Rest combined with programme of exercise, support and counselling

COAD

Goal

▪ To improve function, condition to remain well controlled

Action

▪ Avoidance of bronchial irritants, exercise as tolerated, oxygen therapy as required,

medication reviews

DERMATITIS

Goal

▪ To maintain healthy skin

Action

▪ Avoid allergens, topical treatment and medication as required

depression

Goal

▪ Achieve optimal mental well being

▪ To maintain mood and review need for antidepressant medication. Engage community psychologist.

▪ Help change poor self esteem

▪ Psychological support and monitoring of medications for recurrent depression

▪ Close monitoring of effectiveness of medication ------ with GP

Action

▪ Counselling and support; appointment with psychiatric health professional; review effectiveness of medications

CELLULITIS

Goal

▪ Early detection and treatment of cellulitis

Action

▪ Early introduction of antibiotics

▪ Raised legs whilst sitting

▪ Dressings to affected areas as ordered

CERVICAL DYSPLASIA

Goal

▪ Early detection of any cervical changes

Action

▪ Regular vaginal and vulval coloscopy

DIABETES

Goal: Maintain adequate control of diabetes; To prevent, delay or detect complications of diabetes;

Improved glycaemic control

Action Regular serum glucose profiles, review hypoglycaemics; Biannual HbA1C test to monitor long term maintenance of diabetes; regular visit to podiatrist, annual diabetic eye review, annual cholesterol check and 3-6/12 outside acceptable parameters.

Modify diet and increase levels of physical activity in order to help with weight and diabetes control.

Monitor renal function – annual 24 hour urine collection, micro albumin, urea and electrolytes

Goal To increase knowledge of BSL’s and knowledge of diabetes

Action Review BSL monitoring and keep BSL diary

Dietary

Goal Make dietary changes for long term health. To understand the role of diet and exercise in diabetes management.

Action Attend diabetes education session which will address: healthy eating and lifestyle for diabetics

Education To understand what diabetes is and the type of treatment suited to you.

Goal Action Attend diabetes education session which will address: what diabetes is, medication and monitoring of blood sugar level in the management of diabetes

Foot Care

Goal Maintain good foot care and attend to any new …………………………. Regard to the feet.

Action Requires footcare every three months to ensure good foot health and maintain mobility.

Goal To maintain healthy feet

Problem Difficulty attending own foot care

Action To attend diabetes education session to learn more about healthy foot care and prevention of foot injury, regular visits to podiatrist.

Eyecare

Goal To avoid eye complications

To prevent diabetic retinopathy

Annual review to assess potential diabetic eye complications

Overweight To have a diet of low fat and low glycaemic index foods

DIET – IMPROVE

Goal Weight loss; improve serum cholesterol profiles and blood pressure control.

To develop an exercise regime appropriately suited to aid weight loss, increase muscle strength and improve overall wellbeing.

Action: Review of diet, provide information and follow up diet modification.

DIETICIAN Referrals to dietician as often as dietician recommends to assist reaching target/s if outside of target range.

EARS

HEARING

Goal To improve hearing impairment / to improve the clarity of hearing

Action Provision of hearing aid

Six monthly hearing tests

Regular removal of cerumen an rescreening by audiologist

TINNITUS

Goal To improve clarity of hearing and relief of tinnitus

Action Regular hearing ests; ? playing of music, etc. to mask effects of tinnitus

OTITIS EXERNA

Goal To relief pain in ears and maintain dry and clear ear canals

Action Regular assessment by GP, ear drops as required, use wax to outer ear whilst swimming

EUSTACIAN TUBE BLOCKAGE

Goal To relief pain and feeling of blocked ears

Action Rhinocort spray to reduce polyps in Eustacian Tubes and improve patency

EMPHYSEMA

Goal To maintain oxygen saturation rates at optimal level

Action Regular reviews with specialist, oxygen therapy (at home 2L/minute etc) as required, regular Hb checks

EPILEPSY

Goal To remain well controlled

EYES

Goal Reduction of thrombo-embolic episodes

Treatment of cataracts

Action Reviews, upgrade of glasses

MACULAR DEGENERATION

Goal Assessment of ongoing visual degeneration and management

Action Opthamologist review, assistance with daily needs when and if necessary

VISION

Goal Monitor vision status

Monitor refractive status and maintain optimal visual acuity

Monitor IOL implants for stability and posterior capsular thickening

Monitor retinal integrity

Monitor corneal surface integrity for chronic dry eye, eyes to be adequately hydrated

Monitor retinal vasculature for Warfarin toxity

Action Regular review and awareness of visual deterioration

Annual assessment of eyes to monitor visual acuity and eye disease

Provision of aids to ensure home safety through Vision Foundation Australia

FIBROMYALGIA

Goal Relief and control of pain

Action medication as required, exercise, local application of heat and massage as tolerated.

FRACTURES

HIP – Post Surgery

Goal To maintain optimal joint mobility and express relief of pain

Action Regular review, physiotherapy and exercise

GASTRIC REFLUX

Goal Keep symptoms under control

To control pain due to reflux

Action To modify diet and monitor effectiveness of Nexium

GOUT

Goal To attain an optimal level of functioning within the physical limitations of gouty arthritis; the patient will demonstrate an understanding of the disease and its treatment goals by adhering to a prescribed regime, including diet, exercise, rest and medications.

Goal To maintain joint mobility and be pain free.

Action Discuss …. GP prescribed regime including diet, exercise, rest and medications.

HAEMOCHROMATOSIS

Goal Serum Ferritin levels to be within acceptable parameters, prevention of liver disease.

Action Regular review with haematologist, regular venesections inrelation to serumferritin levels.

HEPATITIS C

Goal To achieve optimal physical well being, to prevent any transmission of Heptatitis C.

Action Ongoing monitoring; counselling and support; care should be taken in areas where transmission of Hepatitis C through blood may occur.

HERPES – GENITAL

Goal Symptomatic treatment of sores; to prevent any further transmission of Genital Herpes.

Action Keep sores dry and clean, salt baths, rest, analgesia, cotton underwear; prevention of transmission by use of condoms and avoid sexual contact if sores present.

HODGKIN’S DISEASE

Goal Arrest disease, maintain quality of life for as long as possible.

Action Regular review of medications and blood tests.

MEMORY LOSS / CONFUSION

Goal Improve mental state

Improve memory loss

Action Maintain and closely observe therapeutic dose of medication

Need for health assessment

MIGRAINE

Goal To assist in preventing migraine headaches by reducing probable stimuli, relief and control of pain.

Action Education and provision of appropriate medication.

MULTIPLE SCLEROSIS

Goal To reduce frequency of neurologic exacerbations. Perform activities of daily living with minimal or no restrictions.

Action Requires visit to neurologist, ongoing monitoring of medication. Maintain as normal and active a life as possible, avoiding over work and fatigue.

GUIDELINES FOR GPS CARING FOR PATIENTS WITH LYMPHOEDEMA

Goals of Treatment:

1. Minimise swelling.

2. Rduce risk of complications (especially cellulitis) and reduce long term changes due to limb lymphoedema (skin and joint changes).

3. Minimise psychological impact.

Actions:

• Encourage self-management activities – skin care, self massage and exercise.

• Avoid affected limb for injections and blood pressure readings.

• Check garments (if required) are replaced 4-6 monthly.

• Check that there is annual (as a minimum) review by a qualified therapist.

• Treat episodes of cellulitis at an early stage, to prevent further damage to the lymphatic vessels, and further exacerbation of the swelling. Consider long term antibiotics for recurrent cellulitis.

For lower limb:

• Treat tinea aggressively to reduce the risk of episodes of cellulitis.

• Arrange podiatry if necessary.

All patients:

• Encourage weight towards the healthy range.

• Encourage regular activity.

• Monitor psychological wellbeing. Suggest support group.

Travel care:

• Refer to therapist for advice regarding garments for long car journeys and flights over 3-4 hours.

• Consider supply of antibiotics if significant risk of cellulitis.

OESOPHAGEAL REFLUX

Goal Control of reflux

Action Review symptoms and monitor effectiveness of medications.

OSTEOARTHRITIS

Goal To maintain optimal joint mobility and express relief or control of pain.

Action Assess level of discomfort; monitor side effects of anti-inflamatory agents and analgesics.

OSTEOPOROSIS

Goal Relief and control of pain

Maintain bone mineral density

Action Appropriate medication and physiotherapy

Maintain physical activity to prevent atrophy and further bone deterioration / destruction.

Fosamax each Sunday

Walking as weight bearing exercise.

PAIN

PHYSIO

Goal Regain improved function in ……… and perform activities of daily living with minimal or no restrictions.

BACK PAIN

Goal Relief and control of pain

Action Appropriate medication and physiotherapy.

LEG PAIN / FALLS / LOSS OF BALANCE

Goal To maintain optimal joint strength, control and mobility and express the relief or control of pain.

Action Reinforcement of fall and balance programme. Ongoing monitoring of medications. Continue with home exercise programme.

Therapeutic exercise programme.

Graduated exercise rehabilitation programme.

Assess functional tolerance and physical capacity.

Engage in a physically directed rehabilitation programme.

Exercise programme under supervision of physio.

Programme designed to meet Mrs….. needs

NECK

Goal Relief and control of pain; return to normal functioning ability

Action Medication as required, engage in rehabilitation programme as directed by specialist / physiotherapist.

SHOULDER

Goal Relief and control of pain. Attain and maintain optimal functioning ability.

PARKINSON’S DISEASE

Goal Reduce neurological deficits associated with Parkinson’s Disease.

Action Monitoring of medication

PERIPHERAL NEUROPATHY

Goal To maintain optimal mobility

Action Regular review with neurologist, medication and treatment as prescribed.

PERIPHERAL VASCULAR DISEASE

Goal To improve vascular function and prevention of complications.

Action Order for compression bandage / stocking, regular assessment.

PODIATRIST

Goal Provide footcare and education relating to maintaining healthy feet.

To attain an optimal level of functioning.

Maintain good footcare and attend to changes/deterioration.

Action Annual review of feet, assessing for foot complications.

Annual review to three monthly review of feet

General care of feet and maintenance of orthotic therapy as required.

Required footcare every three months to ensure good foot health and maintain mobility.

Two monthly care – general treatment – keep feet healthy, free of injury and optimising his / her mobility.

POLYCYTHAEMIA

Goal Condition to remain well controlled.

Action Regular blood tests and treatment as indicated by test results.

PSORIASIS

Goal To improve skin health and prevent any complications.

To control psoriasis

Action Educate patient re skin care and apply appropriate skin preparations.

PROSTATE – POST SURGERY

Goal Maintain urine flow at optimal level

Action Review with urologist if further bleeding, regular PSA and blood tests.

RENAL FAILURE

Goal Maintain renal function for as long as possible.

Action Commence on EPO injections weekly. Regular blood monitoring.

RHEUMATOID ARTHRITIS

Goal Arrest disease, maintain mobility, prevent deformity, be pain free.

Action Regular medications, prednisolone, orudis/folic acid, regular blood tests to monitor effects of medication, regular review by specialists, regular exercise.

ROTATOR CUFF INJURY

Goal Obtain and maintain a passive range of left / right shoulder motion

Restoration of normal function

Relief of pain

Action Strengthen rotator cuff – left / right shoulder

SLEEP APNOEA

Goal To achieve an adequate sleep pattern appropriate to individual needs.

Greater confidence to manage COPD, adequate oxygenation overnight.

Control sleep apnoea and maintain alertness during the day by ongoing use of nasal CPAP.

Action Determine type of sleep disturbance being experienced and the cause.

Regular follow up with GP / Respiratory specialist

Bronchial hygiene including sputum clearance techniques

Bipap overnight

Pulmonary Rehabilitation – Cedar Court

O2 Concentrator

Goal Faultless continuous supply of oxygen

Action Regular maintenance, checking connections and alarm systems

THYROID

HYPOTHYROIDISM

Goal Condition to remain well controlled and asymptomatic

Action TFT, monitor medications

ULCERS

Goal To heal leg ulcers and achieve healthy skin integrity

Action Dressings as required, dressings to remain dry, leg elevated when sitting

VAGINAL PROLAPSE

Goal Condition to remain well controlled

Action Pessary to remain in place

WARFARIN

Goal To prevent the possibility of a thrombo-embolic complication

To prevent clots and maintain blood tests within acceptable parameters

Action Regular blood tests checking INR levels

WEIGHT MANAGEMENT

Goal To have a diet that promotes good health and includes low fat and low glycaemic index foods.

To establish a regular exercise routine.

Action Education regarding healthy eating to aid in weight loss

Maintain regular exercise

Nutritional guidance

Modify diet and increase levels of physical activity in order to help with weight control

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