Name:Heather Wilton
Address: Heims Drive
Contact no:111 8989
Doctor:Dr Ricky
Medicare no:83332 45454
Date of birth:1960
Doctor’s contact no:333 3330
Pension no:22244 56565 C
Individualised Care plan
Care alerts (write in red)
For example: allergies, drug reactions, smoker, falls risk, diabetic
Falls risk
Communication
Preferred name: Heather
Care needs: Comprehension difficulties
Goal: (expected outcome) Comprehension difficulties will reduced
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)
Short term memory loss
Orientate to correct time
Speech disorder/s
Translate for care recipient
Take time to listen
Initiate conversation
Use language cards
Use picture cards
Other
Mobility
Care needs: Walks independently, gait unsteady. Falls risk. Refuses to use walking aid.
Goal: (expected outcome) Current level of mobility will be maintained in a safe manner.
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:Heather Wilton
Address: Heims Drive
Contact no:111 8989
Doctor:Dr Ricky
Medicare no:83332 45454
Date of birth:1960
Doctor’s contact no:333 3330
Pension no:22244 56565 C
Individualised Care plan
Provide direction
Supervise movement
Encourage to maintain mobility
Other
Toileting and continence
Care needs: Incontinent of urine
Goal: (expected outcome) Client will remain comfortable and dry. Skin integrity will be maintained.
Continence
Bladder control
continent
incontinent
Bladder management
Toilet (times
catheter
( occasionally frequently total incontinence )
)
Other Toilets self
Bowel control
Bowel management
continent incontinent constipation colostomy ( occasionally frequently total incontinence )
Continence aids
Toileting
Day Small Pad
Toileting aids
commode
over-toilet frame
Toileting regime
independent
Adjust clothing
high fibre diet
encourage fluid intake
aperients
bowel chart
Night Medium Pad
urinal
uridome
kylie
bed pan
Other Uses toilet
supervise
Position on toilet
some assistance/prompt
fully assist
Encourage self care
Clean perianal area
Other
Showering, dressing and grooming
Care needs: Unable to adequately complete personal care tasks self
Goal: (expected outcome) Adequate level of personal care will be maintained
Shower and washing
independent
shower
supervise
bath
Frequency Daily
some assistance/prompt
bed sponge
flannel wash
fully assist
Preferred time O830hrs
Adjust water temperature
Encourage to optimise self care
Other
Transfer
walk to shower
wheelchair
Showering aids
shower chair
Other Prefers to stand to shower
Toiletries
normal soap
deodorant
Other
aqueous cream
moisturiser ( am pm )
Other
Hair care
Grooming
wash in shower
wash in bath
Hair care
independent
supervise
Hairdresser
Every 6 weeks
Facial hair
wet shave
Preferred days Every 2nd day
some assistance/prompt
dry shave
Hair removal
Nail/foot care
Teeth
Frequency
Frequency
independent
supervise
Podiatry visits
NB: Clients Mother attends to nail care
none
fully assist
some ( upper
some assistance/prompt
lower )
fully assist
all
Cleaning routine Prompt to clean after breakfast
Dentures
none
partial
full
( upper
lower )
Night
in
out
Cleaning routine
Grange Home Care
Page 2 of 5
Name:Heather Wilton
Address: Heims Drive
Contact no:111 8989
Doctor:Dr Ricky
Medicare no:83332 45454
Date of birth:1960
Doctor’s contact no:333 3330
Pension no:22244 56565 C
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 Prefers to wear sheep skin boots in & outdoors
Pressure area and skin care
Care needs: Nil
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: Client unable to prepare own meals. Carer assists with breakfast preparation and prepares lunch meal in
advance daily
Goal: (expected outcome) Clients nutritional needs will be met
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 Kitchen
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: Light sleeper, but maintains regular sleep pattern. Sleeps independently of sedative medication.
Goal: (expected outcome) Current sleep pattern will be maintained
Usual time to rise 0600hrs
Usual time to bed 2130hrs
Preferred sleeping position On back
music
Rest time
Pillows required x1
Sleep Aids
massage
Room
light on
Night-time patterns
Toilets upon retiring, rises at 5.00am to toilet, then returns to bed.
Other preferences (For
Hot cup of tea before retiring to bed (Mother makes)
door open
door closed
( am pm )
hot packs
bedrail/protectors
Other
Other
example: hot drinks or snacks)
Grange Home Care
Page 3 of 5
Name:Heather Wilton
Address: Heims Drive
Contact no:111 8989
Doctor:Dr Ricky
Medicare no:83332 45454
Date of birth:1960
Doctor’s contact no:333 3330
Pension no:22244 56565 C
Individualised Care plan
Night checks
every hour
every 2 hours
eye drops
ear drops
Other
Medications
Current medications
Blood sugar level testing
Other See list of medications
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
[x ]
Medications
[ ]
Pain management
[ ]
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:
Goal: (expected outcome)
Frequency of visit/contact by family/friends Client lives with Mother Molly Wilton. Sister visits weekly
Religion beliefs/practices
Pastoral requirements
Attends place of worship (day/s
)
Cultural needs
Hobbies/interests Stamp/Coin collection
Employment history Nil
Pets Budgie
Name/s Pippy
Type/s Bird
client manages pet
requires prompt and assistance in pet care
fully assist pet care
Social group/s Attends Community Centre
Preferred activity/games Lawn bowls
Community care social outings Programme within Community Centre
(Frequency: 3 times per wk
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
Washing clothes
Cleaning
Cooking
Transport
Gardening
Other
Grange Home Care
Page 4 of 5
Name:Heather Wilton
Address: Heims Drive
Contact no:111 8989
Doctor:Dr Ricky
Medicare no:83332 45454
Date of birth:1960
Doctor’s contact no:333 3330
Pension no:22244 56565 C
Individualised Care plan
Emotional support
Behaviour
Care needs: Confusion, Short term memory loss, withdrawn.
Goal: (expected outcome) Episodes of confusion, withdrawn state will be reduced.
Orientate to time and place
Remind and reassure about appointments
Spend time talking 1:1
Encourage to socialise, to attend community centre
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
Grange Community Care use only
Entered in progress notes
Signed S Ward
Date
Print name Samantha Ward
Position title Senior Care Worker
Review date every 3 months
Grange Home Care
Page 5 of 5