XXXXXXS CARE PLAN:
The ‘Registered Nurse’ (RN) / Team Leader regularly checks and updates XXXXXX’s care
plan. Support Staff are to speak to the RN/Team Leader if they have any problems or
suggestions regarding XXXXXX’s care.
The RN/Team Leader will communicate any changes, updates or added or deleted records
with all of XXXXXX’s Support staff.
Personal Care
XXXXXXs goals
1.
2.
3.
For XXXXXX to maintain good personal hygiene
To ensure skin integrity is maintained
For XXXXXX to feel good about himself and feel supported with
assistance to achieve these goals
Task
Assistance
required
Frequency Outcome
Showering
Full x 1 staff
Daily/ Prn
Personal hygiene, use dermaveen
on XXXXXXs skin
A5
Shaving
Full x 1 staff
Daily
Clean shaven and neat appearance
A5
Dressing/Grooming Full x1 staff
Daily/ Prn
Neat and appropriately dressed
A6
Skin integrity
Daily
To note any changes, color, texture,
lumps
A5
Observe
More
info
Interventions
1. Don’t say “let’s brush your teeth” as XXXXXX will close his mouth shut. Get
the toothbrush ready then go to XXXXXX.
2. When shaving XXXXXX, seat him in a chair and work from behind him, to
help minimize his behaviours.
3. Have XXXXXX’s clothes ready, take his under pants, socks and singlet into
the bathroom and place into the bottom draw so they don't get wet.
4. Spray deodorant under his arms.
5. Apply cream to back for acne rash, wear gloves when applying creams and
lotions.
6. Document any observation seen, always ensure skin is dry and intact.
7. Comb his hair.
8. Report any concerns regarding skin integrity or issues with behaviour to the
RN/Team Leader.
Nutrition and Hydration
The RN/Team Leader regularly does health checks to monitor blood pressure,
weight, skin integrity etc.
XXXXXXs goals
1. To maintain general health, weight, and hydration
2. To maintain his Low GI Diet
Task
Assistance
Required
Frequency
Outcome
More
info
Drinking Full x 1 staff
Offer fluid every hour
To maintain his hydration
A2
L1
Food
3 meals and 3 snacks
a day
On low GI diet refer to
L1 in care plan
To maintain XXXXXX’s weight, have
good general health and wellbeing
A2
L1
Minimal x 1
staff
Interventions
1. Offer XXXXXX fluid every hour, water, whey powder drink with Almond milk
drink.
2. Fill glass and place it in his hand, if XXXXXX only has a few sips, repeat the
process. Always leave the glass with water at the end of the kitchen bench.
3. Give support to his right arm, to reduce the risk of him dropping the glass.
4. Ketogenic Diet, make breakfast, lunch and dinner, refer to menu planning
5. Serve meals, cut up XXXXXX’s meals into bite size pieces, place food in front
of him, provide XXXXXX with assistance using a fork and spoon.
6. Assist XXXXXX to sit at the table
7. XXXXXX requires full supervision at all times
8. Report to RN/Team leader if XXXXXX is not drinking enough or is not eating.
Medication Administration
XXXXXXs Goals
1. To ensure XXXXXX receives the correct medication as prescribed.
2. To ensure the PRN medication is given as per his Doctors orders, to reduce
the risk of overdose.
Tasks
Assistance Frequency
Outcome
required
Webster Pack
Full x1
For regular
medications
PRN Medications /
As required in
webster pack
Full x1
As Per webster
pack
As per drug chart
/ GP instructions
More
info
For medication to be given
correctly and for XXXXXX to be
appropriately medicated
G1
XXXXXX to remain pain free
and comfortable. Avoid Status
epilepticus and brain damage.
K1
H4
K1
The RN/Team Leader will monitor the administration of all
medication,
Interventions
1.
2.
3.
4.
5.
6.
7.
Make sure the tablets come from the correct time slot in the pack.
Place tablets in XXXXXX's mouth, ensuring your hand is placed under his chin, hand
XXXXXX a glass of water.
If XXXXXX is resistive (spitting his tablets out) place him in front of the bench and replace the
tablets back into his mouth and give the glass of water to him.
Ensure he has swallowed the tablets.
Sign the medication chart in the correct place.
Record date, time, dose, sign example: (20/11/20, 1100 hrs, 2 tablets, Sign)
If unsure about PRN or regular medications speak to the RN/Team Leader
Communication
XXXXXXS GOALS
1. To enable XXXXXX to express his thoughts, needs, desires, and choices.
2. To enable XXXXXX to interact with others in conversation.
Communication
aids
Support/ assistance
required.
Frequency
Outcome
Lightwriter
Physical support at hand,
wrist, or forearm.
When using
communication
Participation and
increased self
esteem.
D, E
I Pad
Set up a device. Physical
support at hand, wrist, or
forearm.
When using a
device to
communicate.
Participation and
promote
creativity.
D, E
Alphabet
Boards
Physical support at hand,
wrist, or forearm.
For quick
communication.
For XXXXXX to
communicate
quicker .
D, E
Yes/ No
responses
Physical support to
forearm or shoulder as
needed.
When a quick
simple response is
required.
XXXXXX will be
able to accept or
reject quickly and
with less support
.
D, E
Choices
Indicate 3 choices in front
of XXXXXX for food,
music, or television/
always have a choice of
“something else” available
to him.
When XXXXXX
needs to make a
simple selection.
XXXXXX will be
able to make
simple choices.
Interventions
1.
2.
3.
4.
5.
6.
7.
8.
9.
Physical support is required for all communication, by supporting
XXXXXXs hand so he can point with his finger.
Place XXXXXX in the wheelchair when communicating with his computer,
I Pad, Lightwriter, as it supports his body and allows him to concentrate
on his fingers.
As communication requires XXXXXX to concentrate, he tires easily. If
XXXXXX becomes tired, stop communicating and give him a break.
Ask Yes/No questions for quick responses from XXXXXX example:
(Would you like a smoothie for breakfast. He will respond yes or no on the
alphabet board on the fridge, or the yes no signs on the bench)
If XXXXXX indicates a no response offer another breakfast option.
Give three choices then say something else if he is not happy with the
three choices.
Give XXXXXX time to respond if he feels pressured, he finds it harder to
communicate.
Ask one question at a time
Report to RN/Team Leader if there are any issues with XXXXXX’s
communication or if you have had a particularly successful
communication interaction with XXXXXX.
More info
Q2 / Q7
D2
Mobility and Dexterity
The RN/Team Leader will monitor the effectiveness of XXXXXX’s Physiotherapy
plan and liase with the Physiotherapist.
XXXXXXs Goals
1. To maintain his independence.
2. To improve his mobility and balance.
3. To build up his core body strength.
Task
Assistance required
Frequency
Outcome
More info
Physiotherapy
Full x1
As required
To build muscle tone
B
Treadmill
Full x1
As required
To build muscle tone
B2
Walking
Full x1
As required
To build muscle tone
B2
Swimming
Full x2
As required
To build muscle tone
Interventions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
To follow the physiotherapy plan.
Aim for each day- Walk on treadmill 5-10 minutes
Walk outside x 10-30 minutes, encourage XXXXXX to look ahead and lift
his feet.
Beach and forest walks.
Exercises Biceps curls (holding velcro 0.5mg - 1kg weights) reps x 10, 2 sets each
repeat both arms
Hand to ceiling (holding velcro 0.5- 1.0kg weights reps x 10, 2 sets,
repeat both arms
Try indoor soccer/basketball with a soft ball.
Throw/catch with a textured ball
Ensure XXXXXX is wearing his ankle support brace when exercising.
If unsure of physiotherapy interventions speak to the RN/Team Leader.
Risk and Safety Management
The RN/Team leader will frequently review and update the risk management plan.
XXXXXXs Goals
1.
2.
3.
Task
To ensure XXXXXX is as safe as possible with minimal constraints.
To ensure XXXXXX feels secure and his environment is free from clutter.
To minimize the risks XXXXXX faces every day.
Assistance required
Frequency Outcome
More
info
Hazards
Assist x1 at all
times
Constantly For XXXXXX to remain safe
To assess the
risks
Assist x1
constantly
To ensure XXXXXX feels
secure
Interventions
1.
2.
3.
4.
5.
6.
To never leave knives or forks on the bench, as XXXXXX will pick them
up and tap his teeth with them and could injure himself.
Maintain all areas inside the house free from clutter, as XXXXXX will pace
around the living areas and could trip/ or fall when he has a drop seizure
When cooking, place XXXXXX in his wheelchair and involve him in the
cooking, as when he is left to wander he could burn himself.
Ensure the safety switch is on when not using the oven or hotplates, as
XXXXXX will fiddle with the knobs and turn the stove on.
Make sure the safety alarm mats are on and working every shift.
Report any potential hazards to RN/Team Leader.
Head Injuries
Management Plan: Mild
1.
2.
3.
4.
5.
6.
7.
8.
9.
Assess XXXXXXs head and neck before moving him- he will grimace if
touched and is painful.
Complete a Glasgow Coma Scale assessment on XXXXXX before getting
him up.
If XXXXXX is unconscious or vomited more than once, ring ambulance/
team leader.
Monitor for signs of concussion- this is a mild traumatic brain injury that
alters the way the brain functions. The signs include altered levels of
consciousness, headaches, confusion, dizziness and visual disturbance.
Assess for any injuries such as cuts, bruising ,check if he can move his
limbs.
Apply first aid if required.
Nothing to eat or drink for 4hrs post the head strike.
Documentation- falls chart, incident report, daily diary
In any concerns contact the RN/Team Leader.
Moderate to severe:
1.
2.
3.
If blood or clear fluid is escaping from the ears or nose keep XXXXXX on
the left lateral position, ring ambulance/ RN/Team Leader.
If XXXXXX is unconscious for more than five minutes, which means not
responding to any stimuli, ring ambulance/ RN/Team Leader
Complete all documentation as soon as possible.
Continence Management
The RN/Team leader will frequently review and update the risk continence plan.
XXXXXX Goals:
1.
To ensure XXXXXX remains continent
B
2.
3.
4.
5.
6.
To regulate XXXXXXs bowel and bladder patterns
To maintain fluid intake 2.0 liters daily
To maintain privacy and dignity at all times
To ensure exercise to aid with bowel elimination
To ensure skin integrity dry and intact
Interventions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Scheduled toileting times, (every two hours until bedtime) No longer than
5 minutes on the toilet
Do not ask XXXXXX if he needs the toilet, take him as per the the
scheduled times
Pre and post toilet hygiene
Aid XXXXXX with re- adjusting clothes
Staff to remain with XXXXXX at all times when using the bathroom
Ensure the bathroom door is closed when using the toilet
If incontinent please document time, bowels/ bladder on toileting
schedule
Observe for any changes to his skin
XXXXXX to wear pull ups when going to bed and have waterproof
protection on his bed.
Report any continence issues or changes to the RN/Team Leader.
Outcomes
1.
2.
3.
4.
For XXXXXX to remain continent
To ensure XXXXXX has maintained a regular bowel and bladder regime
To ensure XXXXXX is well hydrated
For XXXXXX to sleep well and maintain his personal hygiene
Transport and Escort
The RN/Team leader will organise any services or repairs to XXXXXXs’s car.
XXXXXXs Goals
1. For XXXXXX to live a full active life in his community and beyond.
2. For XXXXXX to travel safely and feel safe in the car.
Task
Assistance required
Frequency Outcome
More
info
XXXXXXs
car
Carers to drive
XXXXXXs car
Anytime
C, H5
To ensure XXXXXX reaches his
goals in the community
Interventions
1.
2.
3.
4.
5.
6.
4.
5.
Assist XXXXXX to the car and to get in/out of the car.
The child proof lock on the back door must be on.
Ensure his seat belt is properly fastened.
Make sure the car is refuelled for the next shift and place the receipt in
the book.
Ensure the car is clean at the end of your shift, cord free vacuum is on
charge in the shed.
Once a month take though the car wash.
XXXXXX is not responsible for any speeding or parking fines.
If concerns about XXXXXX’s car report these to the RN/Team Leader.
Use of Wheelchair – Short term only
The RN/Team leader will review and update the use of the wheelchair on a regular basis.
XXXXXXs Goals
1.
2.
3.
4.
To ensure XXXXXX’s safety
To reduce the falls risk
To provide body support while aiding XXXXXX to achieve his goals
(communicating, painting, writing, and social outings, meal preparation)
For use in emergencies- Fire while preparing to leave house/ Venus Bay
Interventions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
While preparing to move due to potential fire outbreak, so care staff know
where he is at all times
The chair allows staff to move XXXXXX quickly to a safer environment as
needed
When going away from home for an extended period, place chair in car
boot
If XXXXXX is unsteady on his feet, or his balance is off, place XXXXXX in
his wheelchair for his safety
Every hour XXXXXX is to have a 15-minute break from the wheelchair,
take him for a walk and to the toilet as per his scheduled toilet times
Always ask XXXXXXs approval for going in the wheelchair (except if it’s
for his safety, reasons must be documented in daily diary)
Do not leave XXXXXX without any stimulation whilst in his chair, music,
audible books, reading etc.
Place lap buckle under his shirt as he may unbuckle it while fiddling with
it. Staff can place XXXXXX in his wheelchair when they need to use the
bathroom for XXXXXX’s safety whilst you leave the room (ask XXXXXX if
it’s ok to sit in the chair whilst you go to the toilet)
Always ask XXXXXX if he is ok with staying in the chair- direct questions
Yes/No responses, if unsure use yes/no indicators on the kitchen bench
When XXXXXX is communicating using the computer, ipad, or lightwriter,
place XXXXXX in wheelchair to support his core body
Any problems with XXXXXX’s use of the wheelchair, or mechanical
issues with the chair itself, should be reported to the RN/Team Leader.
Outcomes
1.
2.
3.
4.
XXXXXX will have a reduced falls risk, and ensure his safety
XXXXXX will be able to communicate and have more control over his
fingers, if he doesn't have to think about his core body movement
To improve achieving his goals
To assist XXXXXX if he crashes and is unable to walk
When the Chair should Not Be Used
1.
2.
3.
It is NEVER to be used as a restraint
It should not be used as an alternative to XXXXXX walking himself should
he be able to do so
It should never be used as a disciplinary measure
Nursing and Allied Health Services
The RN/Team leader will organise in-services for staff and liase with Allied Health workers
regarding XXXXXX’s program.
XXXXXXs Goals
1.
2.
To enable XXXXXX to live a healthy and active life.
To in-service support staff on matters of diet, general health and mental and
physical wellbeing, medication administration, sleep, continence etc.
Item
Support required
Frequency
Outcome
Nursing
Medication, Diet,
General Health, first
aide, record keeping, inservicing staff, rostering
of staff.
When required
and new staff.
XXXXXX will
live a healthy
and active life
and staff will
approach their
role with
knowledge and
confidence.
G
Physiotherapy
In-service of support
staff. Personal physical
program for XXXXXX.
3 monthly
Support staff
will be able to
assist XXXXXX
with his physical
program on a
daily basis with
knowledge and
confidence.
B
Monthly
XXXXXX will
have short cut
toe nails.
Review of progress.
Podiatry
Toe nail cutting
Ankle brace
Toe support
Ankle brace and
toe support will
assist when
mobilizing.
Toe support will
ensure he
doesn’t wear
hole in the
insoles of his
shoes.
Dietician
Checking and
monitoring XXXXXX’s
Ketogrnic diet
Cooking Ketrogenic
means and snacks.
RN/Team Leader
creates menu in liason
with the Dietician.
Monthly
XXXXXX will
maintain a
healthy, varied
Ketogenic diet.
XXXXXX will
have fewer
epileptic
seizures.
More info
Behaviour Management
The RN/Team leader will update XXXXXX’s behaviour management plan and in-service support
workers regarding intervention strategies.
Behaviour Goals
1.
2.
3.
4.
Keeping my hands to myself.
Staying with my support worker and don't wander off.
To pick up my feet when walking and not kick at stones.
Not to hurt carers when pinching/ lashing out.
Behaviour:
Interventions:
Outcomes:
Pinching and
hitting/lashing out.
To hold XXXXXX from behind or beside
when assisting him to walk.
Minimizes him
hurting
himself.
Support
workers or
others close
by.
Maintain
acceptance in
the
community.
Wandering
Maintain visual sight of XXXXXX at all
times.
XXXXXX will
feel confident
and
supported.
XXXXXX will
remain safe.
Dragging feet and
Ankle brace when mobilizing
kicking stones.
Reminder to lift feet and not kick stones.
XXXXXX will
be able to
walk over
rough terrain.
He will avoid
tripping and
falling.
Any issues with XXXXXX’s behaviour need to be reported the RN/Team leader.
More info
Toileting Schedule: EXAMPLE
Date
Day
Mon
Bladder/
Bowel
Time
XXXXXX is to be toileted two hourly.
0700
0900
1100
1300
1500
1700
1900
2100
2300
C/ PU
D
T4/C
D
D
D
I/PU
D
D
LG
Tues
Wed
Thur
Fri
Sat
Sun
Mon
Tues
Wed
Thur
Fri
Sat
Sun
LEGEND:
If XXXXXX urinates and is continent, mark C/ PU or I/PU passed urine in appropriate time
and day
If XXXXXX uses his bowel’s, mark C- continent, I – incontinent, use bowel chart T1,2,3 then
amount LG, MED, SM
C
= Continent (urinated successful on toilet)
I
= Incontinent (involuntary loss of urine)
D
= Dry (when checked and did not urinate)
Mark as Continent, Incontinent, or Dry in hour checked.
OVERNIGHT CODE:
S – Asleep A – Awake but Settled O - out of bed W – Wet X – Attention
Instructions
Fill this in each night. Keep comments clear and note times for each item in each
hour. Use the codes at the top for clarity and consistency.
MONDAY
Date
11
12
Worker
1
2
Checked
Team
Leader
3
4
5
6
TUESDAY
Date
9th Jan
11
Worker
1
Checked
Team
Leader
3
11.30 (S)
3.45 (A) settled, placed radio
on
12
12.45 (O)
Back to bed 12.50
2
2.15 (W) (X)
4
4.20 (S)
back in bed 2.45
Rechecked 3.55 (S)
5
6
Notes: 9th Jan 02.15 Tues changed bedding, gave XXXXXX a wash, clean Pj’s back in bed
………………………………………………………………………………………………………………
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