OVERALL PLAN OF CARE



OVERALL PLAN OF CARE

RESIDENT NAME: DALE ROOM #: ADMIT #: ADMIT DATE: PHYSICIAN:

DIAGNOSIS: DELUSIONS, DEMENTIA, CLASS III NON-ISCHEMIC CARDIOMYOPATHY WITH AN EJECTION FRACTION OF 15-20%, PATENT FORAMEN OVALE, AORTIC REGURGIATION, CHF, CAD, ATRIAL FIBRILLATION, HTN, BIVENTRICULAR IMPLANTABLE AUTO CARDIOVERTER/DEFIBRILLATOR, COPD, SLEEP APNEA, ID DIABETES, CHRONIC KIDNEY DISEASE, BPH, URGE INCONTINENCE, HEARING LOSS, GERD. HX: SOB, PERIPHERAL VISION FIELD CUT, PNEUMONIA, WEST NILE VIRUS 2003, LT. KNEE ARTHROPLASTY, CHOLECYSTECTOMY, TURP, HYPOXIA, PNEUMONIA.

DATE PROBLEM GOAL APPROACHES

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02/16/17 #1 Nutritional compromise RT a. Will eat 75-100% of meals to be Diet: Provide with a Regular CAT diet with sugar free drinks. He selects foods of his choice from the menu. He is not compliant

(Nutrition, weight loss, dementia & diabetes able to maintain weight & nutritional with a NCS diet.

Cog, Comm, AEB needs encouragement to eat. integrity by 05/10/17. Diet/Nsg: Encourage him to eat 75-100% of all meals maintain adequate nutrition. Document in Care Tracker.

Behavior, He is a regular diet. He has GERD b. Will have no ADR’s from the Nsg: He sometimes needs verbal cues & assistance with eating. He is in the Courtyard Square Dining Room.

Mood) & is on scheduled *Omeprazole *Omeprazole by 05/10/17. Nsg: Weekly weight & record in Ultra Care. Re-weight for 3 or more lb. discrepancies. Notify the CDM & ADON of 3 or more lb.

for GERD. His edema fluctuates. Current Weight: 182.6 lbs. weight discrepancies. Nursing is monitoring his edema status.

Current Height: 70 inches. Diet/Res/Nsg: Monitor the need for adaptive devices & positioning at the dining room table.

Nsg: Monitor the effectiveness & side effects of the *Omeprazole & keep MD informed.

02/16/17 #2 Inability to dress himself RT Will assist with dressing himself Res/Nsg: Explain tasks to him prior to beginning. He has a peripheral vision field cut. See MD notes.

(ADL’s, Cog, dementia & visual field cut AEB daily by 05/10/17. Res/Nsg: Lay out the clothes of his choice & encourage him to dress himself as much as possible. Assist PRN.

Comm, Mood, needs assistance. Res/Nsg: Encourage him to do his other ADL’s on his own after set-up. Praise him for all accomplishments.

Behavior)

02/16/17 #3 Potential for falls RT dementia a. Will have no falls by 05/10/17. Res: Follow the Restorative Flow Sheet for specific exercises 3 X weekly.

(Falls, Pain, poor safety awareness & poor b. Will have pain at a tolerable Res/Nsg: He transfers with a walker & 1 assist. He needs a pressure sensitive alarm in his chair. He has very little safety

Cog, Comm, balance AEB needs a walker, level for him by 05/10/17. awareness. He uses his wheelchair independently. Ambulate with walker & 1 assist daily.

Behavior, gait belt & 1 asssit for transfers c. Will remain in safe areas Res/Nsg: He wears a Roam Alert Bracelet to assist him with remaining in safe areas.

Mood) & ambulation. by 05/10/17. Nsg/Res: Monitor the need for additional Fall Protocol initiation & notify family of safety options.

Fall Assessment: 19 – High Risk. Nsg: Monitor for s/s pain per protocol & document on the Pain Assessment. Offer Non-Pharmalogical interventions prior to

offering a PRN pain med per order. Offer a gentle back rub as he allows. Document effectiveness. Anytime he complains of pain,

it is to be documented on the Pain Assessment.

02/16/17 #4 Potential for dehydration RT a. Will take adequate fluids of Nsg: Encourage fluids throughout the day in addition to meals & document in AHT.

(Dehydration, diuretic use AEB needs a lot of 1500-2000cc in 24 hours Nsg: Observe for s/s dehydration (Dry mucous membranes, decreased skin turgor, change in mental status, decreased urinary

Cog, Comm, reminders to drink between meals. by 05/10/17. output, concentrated urine) & notify MD.

Behavior, K+: 4.4 on 1-8-17 (3.5-5.2) b. Will have electrolytes within Nsg: Day & Evening shifts to offer an additional 240cc each & document in Care Tracker. Document all refusals.

Mood) Na++: 138 on 1-8-17 (3.5-4.6) normal range by 05/10/17. Nsg: Medication Nurse to document fluid totals given with meds in Care Tracker.

c. Will have no ADR’s from Nsg: Monitor edema monthly & per protocol & document on the Monthly Summary & Edema Flow Record.

the *Furosemide, & *Spironolactone, Act: Document fluid totals given with activities in Care Tracker.

by 05/10/17. All: Make sure he knows where the pitcher is in his room. Make sure fluids are placed in line of his vision. He has problems with

his peripheral vision at times.

Nsg: Observe s/s constipation & offer Prune juice, Go Cookie, & or Bran Mix daily. If non-pharmalogical efforts fail, offer him a

laxative PRN per order. Document results in Care Tracker.

Nsg: Observe effectiveness & side effects of the *Spironolactone & *Furosemide & keep MD informed. Draw labs per order &

notify the MD of results.

02/16/17 #5 Potential for skin breakdown RT a. Will have no red or open areas Nsg: Observe s/s red or open areas throughout each shift & notify the Charge Nurse. Pressure relieving devices for her bed.

(Pres-Ulcer, urge incontinence & rare involuntary by 05/10/17. Nsg: He is able to tell you when he needs to use the bathroom. Prompt & assist him use the bathroom/commode when he gets up

Urinary, Cog, BM AEB wears an incontinence brief. b. Will have ................
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