Care plan template
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Care plan Care alerts (write in red) Name: Agnes Jean MacDonald Date of birth: 1/12/1916 Address: 58 Lilac Lane Potsville Contact no: 9333 9999 Doctor: Dr Alan Trudeaux Doctor’s contact no: 9333 3333 Medicare no: 6999 12345 6 Pension no: 9999999999Z For example: allergies, drug reactions, smoker, falls risk, diabetic Diabetic Communication Preferred name: Agnes Care needs: Goal: (expected outcome) 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 responses) Language/s spoken English Speech disorder/s Translate for client Take time to listen Initiate conversation Use language cards Use picture cards Other Mobility Care needs: Goal: (expected outcome) Ambulation (walking) ambulant (able to walk) non-ambulant (unable to walk) Aids walking stick zimmer frame wheelchair quad stick wheeled walker Other 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 Provide direction Supervise movement Encourage to maintain mobility Other Grange Home Care Care plan Page 1 of 5 Name: Agnes Jean MacDonald Date of birth: 1/12/1916 Address: 58 Lilac Lane Potsville Contact no: 9333 9999 Doctor: Dr Alan Trudeaux Doctor’s contact no: 9333 3333 Medicare no: 6999 12345 6 Pension no: 9999999999Z Care plan Toileting and continence Care needs: Potential for skin breakdown due to incontinence Goal: (expected outcome) To maintain good skin integrity Continence Bladder control continent Bladder management Toilet (times 0600 1000 1400 incontinent catheter ( occasionally frequently total incontinence ) 1600 2000 ) Other Bowel control Bowel management continent incontinent constipation colostomy ( occasionally frequently total incontinence ) Continence aids Toileting Day medium pad Toileting aids Commode at night over-toilet frame Toileting regime high fibre diet encourage fluid intake aperients bowel chart Night overnight pad independent Adjust clothing urinal uridome kylie bed pan Other supervise Position on toilet some assistance/prompt fully assist Encourage self care Clean perianal area Other Showering, dressing and grooming Care needs: Potential for infections related to incontinence Goal: (expected outcome) To maintain optimal personal hygiene 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 aqueous cream moisturiser ( am pm ) Other Hair care Grooming wash in shower Hair care independent wash in bath Preferred days Fridays supervise some assistance/prompt wet shave dry shave supervise some assistance/prompt fully assist Hairdresser Facial hair Hair removal Nail/foot care Frequency Frequency independent fully assist Podiatry visits Teeth none some ( upper lower ) all Cleaning routine Dentures none partial full ( upper lower ) Night in out Cleaning routine Grange Home Care Care plan Page 2 of 5 Name: Agnes Jean MacDonald Date of birth: 1/12/1916 Address: 58 Lilac Lane Potsville Contact no: 9333 9999 Doctor: Dr Alan Trudeaux Doctor’s contact no: 9333 3333 Medicare no: 6999 12345 6 Pension no: 9999999999Z 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) [ ] 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 morning Eating and drinking Care needs: Goal: (expected outcome) 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 armchair with tray on lap 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 0600 Usual time to bed 2130 Rest time Preferred sleeping position Pillows required Sleep Aids massage music Room light on Night-time patterns Leaves bathroom light on. Sometimes wakes in the night and reads. door open ( am 2 pm ) door closed hot packs Other bedrail/protectors Other Other preferences (For example: hot drinks or snacks) Night checks Grange Home Care every hour every 2 hours Care plan Other Page 3 of 5 Name: Agnes Jean MacDonald Date of birth: 1/12/1916 Address: 58 Lilac Lane Potsville Contact no: 9333 9999 Doctor: Dr Alan Trudeaux Doctor’s contact no: 9333 3333 Medicare no: 6999 12345 6 Pension no: 9999999999Z Care plan Medications Current medications Blood sugar level testing eye drops ear drops Other 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 [ x] Therapy [ ] Restraint management OHS Completed injury risk assessment forms Home environment Client assessment Yes Yes No No Social and human needs/activities Care needs: Potential for social isolation Goal: (expected outcome) To ensure Sybil has opportunity to develop and maintain social networks Frequency of visit/contact by family/friends Monthly visits by daughter and son-in-law. Has close friendship with neighbour who checks on Sybil daily. Religion beliefs/practices Lutheran Pastoral requirements Attends place of worship (day/s Sundays – picked up and taken to Church by parishioners. ) Cultural needs Hobbies/interests Embroidery, Photography, Art Employment history Retired secretary Pets Name/s Marmalade Type/s Ginger Cat client manages pet requires prompt and assistance in pet care fully assist pet care Social group/s Bridge club – Wednesday afternoons picked up by friends Preferred activity/games Bridge Community care social outings (Frequency Once weekly ) 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 required for appointments and outings Gardening – Lawn mowing and edges fortnightly, weeding/pruning assistance monthly Other Grange Home Care Care plan Page 4 of 5 Care plan Name: Agnes Jean MacDonald Date of birth: 1/12/1916 Address: 58 Lilac Lane Potsville Contact no: 9333 9999 Doctor: Dr Alan Trudeaux Doctor’s contact no: 9333 3333 Medicare no: 6999 12345 6 Pension no: 9999999999Z Emotional support Recently widowed, requires time spent to listen and support. Husband name Jim, died last month from sudden heart attack. Behaviour Care needs: Goal: (expected outcome) 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 Tanya Tomlinson Review date every 3 months Grange Home Care Date Print name Tanya Tomlinson Care plan Position title Care Manager Page 5 of 5
