CARE PLAN
GOALS AND ACTIONS
ANOREXIA
Goal:
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Make dietary changes for long term health.
Achieve optimal physical and mental wellbeing.
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Ongoing monitoring/review of diet.
Counselling, support and disease management.
Monitor haematology and blood pressure.
Action:
ALZHEIMER’S DISEASE
Goal:
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Achieve optimal physical and mental wellbeing
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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.
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Observe clinical features
Review of self management
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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
Action:
Monitor:
ASTHMA
Goal:
Medication
Management
Goal
 Prevention and relief of symptoms, patient education
Action
Regular assessments and ensure patient understanding. Regular prescriptions.
Education
Goal
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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
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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
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To achieve and manage adequate bladder control/bowel pattern
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Encourage 9x drinks per day
Limit drinks 2 hours pre bed time
Pelvic Muscle exercises
Continence pads/aids
Action
STRESS INCONTINENCE
Goal
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To maximize urinary continence, provision of comfort
Action
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Education re pelvic floor exercises, provision of continence aids, possible referral to
Women’s Physio Practice
URETHRAL STRICTURE
Goal
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To maintain optimal urine flow
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Regular review with urologist regarding internal urethrotomy and need for dilatations
Action
URINARY TRACT INFECTION
Goal
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Prevent recurring infection
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Adequate fluid intake, education on UTI prevention
Medication as required
Action
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:
Action
Maintain adequate control of diabetes; To prevent, delay or detect complications
of diabetes;
Improved glycaemic control
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
Eyecare
Goal
Overweight
To attend diabetes education session to learn more about healthy foot care and
prevention of foot injury, regular visits to podiatrist.
To avoid eye complications
To prevent diabetic retinopathy
Annual review to assess potential diabetic eye complications
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