Name: Doreen Quek
Address: Banksia House
Contact no:
Doctor: Mike Severn
Medicare no:67895 222 63
Date of birth:15/07/65
Doctor’s contact no:222 3333
Pension no:800013332 A
Individualised Care plan
Care alerts (write in red)
Allergic to Seafood
For example: allergies, drug reactions, smoker, falls risk, diabetic
Smoker
Communication
Preferred name: Doreen
Care needs: Impaired vision. Comprehension difficulties
Goal: (expected outcome) Effective two way communication will be maintained
Vision
Aids
Hearing
Glasses
Magnifying glasses
Clean and fit glasses daily
Able to clean own glasses
Aids
Place objects in range of vision
Read aloud letters/documents
Assist to write
Assist to use telephone
Hearing aids
( right
left )
Adjust volume daily
Check batteries and clean aids daily
Gain attention before speaking
Speak loudly, clearly and directly
Allow extra time for response
Give step-by-step instructions
Use repetition when difficulty persists
Other
Other
Eye care required
Speech and language
Ear care required
Comprehension issues (For example: inappropriate
Language/s spoken English
responses)
Unable to remember time and place
Does not always recognise others
Unable to remember appointments/events
Understands Chinese
Speech disorder/s
Translate for resident
Take time to listen
Initiate conversation
Use language cards
Use picture cards
Other
Mobility
Care needs: Gait unsteady. Walks with wheeled walker
Goal: (expected outcome) Client will maintain current level of mobility
Ambulation (walking)
ambulant (able to walk)
non-ambulant (unable to walk)
Aids
Other
Grange Home Care
walking stick zimmer frame
wheelchair
quad stick
wheeled walker
Transfers
independent weight bearing (able to stand)
non-weight bearing (unable to stand)
1-staff assist
2-staff assist
hip replacement knee replacement
amputee ( left
right )
Aids
bed rail
hoist
slide sheet gait belt
standing hoist
Hoist sling type and position of loop
Other
Page 1 of 5
Name: Doreen Quek
Address: Banksia House
Contact no:
Doctor: Mike Severn
Medicare no:67895 222 63
Date of birth:15/07/65
Doctor’s contact no:222 3333
Pension no:800013332 A
Individualised Care plan
Provide direction
Supervise movement
Encourage to maintain mobility
Other
Toileting and continence
Care needs: Continent of urine and faeces
Goal: (expected outcome)To maintain current continence levels
Continence
Bladder control
continent
incontinent
Bladder management
Toilet (times
catheter
( occasionally frequently total incontinence )
)
Other
Bowel control
Bowel management
continent incontinent constipation colostomy ( occasionally frequently total incontinence )
Continence aids
Toileting
Day
Toileting aids
commode
over-toilet frame
Toileting regime
independent
Adjust clothing
high fibre diet
encourage fluid intake
aperients
bowel chart
Night
urinal
uridome
kylie
bed pan
Other Uses toilet self
supervise
Position on toilet
some assistance/prompt
fully assist
Encourage self care
Clean perianal area
Other
Showering, dressing and grooming
Care needs: Provide supervision with personal care tasks as unsteady in shower
Goal: (expected outcome)Adequate personal hygiene will be maintained
Shower and washing
independent
shower
supervise
bath
Frequency
some assistance/prompt
bed sponge
flannel wash
fully assist
Preferred time
Adjust water temperature
Encourage to optimise self care
Other
Transfer
walk to shower
wheelchair
Showering aids
shower chair
Other
Toiletries
normal soap
deodorant
Other Wheeled Walker
aqueous cream
moisturiser ( am
pm )
Other
Hair care
Grooming
wash in shower wash in bath
Hair care
independent
supervise
Hairdresser
Monthly
Facial hair
wet shave
Nail/foot care
Hair removal
Facial hair
independent
supervise
Preferred days Daily
some assistance/prompt
dry shave
fully assist
Frequency
Frequency As required at beauticians
some assistance/prompt
fully assist
Podiatry visits
Teeth
none
some ( upper
lower )
all
Cleaning routine Prompt to brush after meals
Dentures
none
partial
full
( upper
lower )
Night
in
out
Cleaning routine
Grange Home Care
Page 2 of 5
Name: Doreen Quek
Address: Banksia House
Contact no:
Doctor: Mike Severn
Medicare no:67895 222 63
Date of birth:15/07/65
Doctor’s contact no:222 3333
Pension no:800013332 A
Individualised Care plan
Dressing and undressing
independent
callipers
supervise
splints
some assistance/prompt
fully assist
Other
Cultural dressing
Dressing assistance
bra
singlet
stockings
socks
Assist with selecting clothing
buttons
jewellery
belt
make-up
zips
shoes
Other
Pressure area and skin care
Care needs:
Goal: (expected outcome)
[ x ] low risk
[ ] medium risk
Norton Scale
Score
Pressure relief aids
bed cradle
Pressure area regime
Reposition in bed
Reposition in chair
special mattress (type
)
sheepskin
cushion
[ ] high risk
bedrail/protectors
Other
Frequency
personal chair
Other/specific orders
Skin care
emollient cream to dry skin areas ( daily
twice daily ) Preferred time/s
Eating and drinking
Care needs: Unable to prepare meals self
Goal: (expected outcome)Client will maintain adequate nutritional levels
Eating
independent
right-handed
supervise
left-handed
some assistance/prompt
Preferred place to eat
dining room
bedroom
Type of diet
normal
soft
modified soft (minced)
Special diet
high fibre
diabetic
enteral feeding (PEG/NGT)
fully assist
Other Lounge room in front of television
puree
Special instructions
Aids
modified crockery
built up cutlery
modified cutlery
clothing protector
bowl
lipped plate
Other
Drinking
independent
right-handed
Aids
modified cup
Thickened fluids
level 1
supervise
left-handed
some assistance/prompt
fully assist
clothing protector
level 2
level 3
Type of thickener to be used
Sleep and settling routines
Care needs:
Goal: (expected outcome)
Usual time to rise 0600hrs
Usual time to bed 2230hrs
Rest time
Preferred sleeping position On right side
Sleep Aids
massage
Room
light on
music
door open
door closed
( am pm )
Pillows required Prefers none
hot packs
Other
bedrail/protectors
Other
Night-time patterns
Other preferences (For
Hot Milo before going to bed
example: hot drinks or snacks)
Night checks
Grange Home Care
every hour
every 2 hours
Other
Page 3 of 5
Name: Doreen Quek
Address: Banksia House
Contact no:
Doctor: Mike Severn
Medicare no:67895 222 63
Date of birth:15/07/65
Doctor’s contact no:222 3333
Pension no:800013332 A
Individualised Care plan
Medications
Current medications
Blood sugar level testing
eye drops
ear drops
Other See Doctors list
independent
pre-packed
supervise
measure
some assistance/prompt
self-administer
fully assist
independent
supervise
some assistance/prompt
fully assist
Frequency
Specialised care plans
Refer to specialised care
plans for
[ ]
Medications
[ ]
Pain management
[x]
Wound care
[ ]
Therapy
[ ]
Restraint management
OHS
Completed injury risk
assessment forms
Home environment
Client assessment
Yes
Yes
No
No
Social and human needs/activities
Care needs: Requires social activities to be organised as unable to manage self
Goal: (expected outcome)Social needs will be met
Frequency of visit/contact by family/friends Mother visits on weekends
Religion beliefs/practices Roman Catholic
Pastoral requirements
Attends place of worship (day/s
)
Cultural needs Enjoys Chinese food. Especially Mothers cooking
Hobbies/interests Nature lover Music
Employment history Nil
Pets
Name/s
Type/s
client manages pet
requires prompt and assistance in pet care
fully assist pet care
Social group/s
Preferred activity/games Walks out side
Community care social outings Enjoys all Banksia House organised outings (Frequency
Requirements
Taxi vouchers
Yes
No
)
Domestic needs/activities
independent
Frequency ( daily
Requirements
supervise
nd
every 2 day
some assistance/prompt
weekly
fortnightly
fully assist
Other
)
Shopping Weekly
Washing clothes Every 2nd day
Cleaning Daily
Cooking Daily
Transport Weekly
Gardening Weekly
Other
Grange Home Care
Page 4 of 5
Name: Doreen Quek
Address: Banksia House
Contact no:
Doctor: Mike Severn
Medicare no:67895 222 63
Date of birth:15/07/65
Doctor’s contact no:222 3333
Pension no:800013332 A
Individualised Care plan
Emotional support
Enjoys daily social contact affection from others
Behaviour
Care needs: Can become verbally loud and teary at times
Goal: (expected outcome) Minimise episodes of verbal and teary episodes
Orientate to time and place
Adhere to clients preferred routine
Provide emotional support
Reassure that Mother will visit regularly
Explain that verbal outbursts are not appropriate
Provide diversional activity
Additional comments (For example: special needs, restraint, routines, pain, palliative care, pacemaker)
Terminal care recorded
Yes
No
Date care plan evaluated (document in progress notes)
Signature
P Goodwin
Grange Community Care use only
Entered in progress notes
Signed P Goodwin
Date
Print name Patrick Goodwin
Position title Senior Care Worker
Review date every 3 months
Grange Home Care
Page 5 of 5