initial palliative care plan - ccmcks.org palliative... · alteration in comfort ... initial...

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Page 1 of 7 Initial Palliative Care Plan MEADOWLARK HOSPICE 709 Liberty, Clay Center KS 67432 Phone: (785) 632-2225 Fax: (785) 632-3557 PATIENT: ID No: Admission to hospice: Physician: Allergies: Diagnosis: Discipline: Names: Frequency of visits: Dianne Michaud, RN BSN Anita Droll, RN Donna Lee Fisher, RN Rita Wollenberg, RN Debra Hedke, RN BSN Kirstin Wernecke, LPN Deb Martin, RN BSN Sherry Wiese, RN Christine Smith, RN MS Nursing Paula Cherney, RN Denise Beeson, RN 1-3 x week & PRN, 4-6 x week & PRN, or 5-7 x week & PRN Dawn Thorn, LMSW Donna Coufal, LBSW Katrina Jones, LBSW Social work Marilyn Dressman, LBSW Stephanie Garrison, LBSW Joyce Nelson, LMSW 2-4 x month and PRN Pastoral Care Rev. Susan Sawyer 1 x 3 month & PRN Volunteers Charlotte Topel and Deb Pyle, Volunteer Coordinators Medical Director John Kelley, MD 1. ALTERATION IN COMFORT Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient will demonstrate reduction of discomfort at least to the point of tolerance. Caregiver will understand the contribution to anxiety to pain and will administer anxiolytics effectively. Patient and caregiver will identify 0-10 pain scale. LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated A. Discomfort a/o pain 1. Evaluate pain on scale of 0-5 R = Resolved B. Rest a/o sleep 2. Teach administering pain meds ATC P= Potential C. Anxiety 3. Evaluate pain medication for effectiveness E. Other: 4. Encourage frequent rest periods 5. Teach sign/symptom of anxiety 6. Teach proper administration of medications 1. Evaluation: 2. ALTERATION IN PATIENT / FAMILY COPING Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient/Family will address and resolve issues surrounding terminal illness. LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated A. Accepting terminal diagnosis 1. Discuss patient/family feelings regarding illness R = Resolved B. Understanding stages of grief 2. Explore and employ coping mechanism P = Potential C. Making plans for last stages of life & after death 3. Other emotional support: D. Other: 4. Present printed information 5. Provide good listening & assist with plans PRN 6. Social assessment 7. Ongoing team meeting interaction 2. Evaluation:

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Page 1: Initial Palliative Care Plan - ccmcks.org Palliative... · ALTERATION IN COMFORT ... Initial Palliative Care Plan ( ) Revised 02/21/05 csc Page 2 of 7 MEADOWLARK HOSPICE 709 Liberty,

Page 1 of 7

Initial Palliative Care Plan MEADOWLARK HOSPICE

709 Liberty, Clay Center KS 67432 Phone: (785) 632-2225 Fax: (785) 632-3557

PATIENT: ID No: Admission to hospice: Physician: Allergies: Diagnosis:

Discipline: Names: Frequency of visits: Dianne Michaud, RN BSN Anita Droll, RN Donna Lee Fisher, RN Rita Wollenberg, RN Debra Hedke, RN BSN Kirstin Wernecke, LPN Deb Martin, RN BSN Sherry Wiese, RN Christine Smith, RN MS

Nursing

Paula Cherney, RN Denise Beeson, RN

1-3 x week & PRN, 4-6 x week & PRN, or 5-7 x week & PRN

Dawn Thorn, LMSW Donna Coufal, LBSW Katrina Jones, LBSW Social work Marilyn Dressman, LBSW Stephanie Garrison, LBSW Joyce Nelson, LMSW 2-4 x month and PRN

Pastoral Care Rev. Susan Sawyer 1 x 3 month & PRN Volunteers Charlotte Topel and Deb Pyle, Volunteer Coordinators Medical Director John Kelley, MD 1. ALTERATION IN COMFORT Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient will demonstrate reduction of discomfort at least to the point of tolerance. Caregiver will understand the contribution to anxiety to pain and will administer anxiolytics effectively. Patient and caregiver will identify 0-10 pain scale.

LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated A. Discomfort a/o pain 1. Evaluate pain on scale of 0-5 R = Resolved B. Rest a/o sleep 2. Teach administering pain meds ATC P= Potential C. Anxiety 3. Evaluate pain medication for effectiveness E. Other: 4. Encourage frequent rest periods 5. Teach sign/symptom of anxiety 6. Teach proper administration of medications 1. Evaluation: 2. ALTERATION IN PATIENT / FAMILY COPING Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient/Family will address and resolve issues surrounding terminal illness.

LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated A. Accepting terminal diagnosis 1. Discuss patient/family feelings regarding illness R = Resolved B. Understanding stages of grief 2. Explore and employ coping mechanism P = Potential C. Making plans for last stages of life & after death 3. Other emotional support: D. Other: 4. Present printed information 5. Provide good listening & assist with plans PRN 6. Social assessment 7. Ongoing team meeting interaction 2. Evaluation:

Page 2: Initial Palliative Care Plan - ccmcks.org Palliative... · ALTERATION IN COMFORT ... Initial Palliative Care Plan ( ) Revised 02/21/05 csc Page 2 of 7 MEADOWLARK HOSPICE 709 Liberty,

Initial Palliative Care Plan ( )

Revised 02/21/05 csc Page 2 of 7

MEADOWLARK HOSPICE

709 Liberty, Clay Center KS 67432 Phone: (785) 632-2225 Fax: (785) 632-3557

3. ALTERATION IN COGNITIVE / PERCEPTUAL PATTERN Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Family understanding of changes in communication, cognition and increased knowledge of how to deal with changes. LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I =Initiated A. Cognitive alteration 1. Explain pathophysiology of altered status R = Resolved B. Communication alteration 2. Allow more time for patient to respond when P = Potential C. Confusion / disorientation conversing D. Sensory alteration 3. Anticipate needs to ensure patient safety E. Other: 3. Evaluation: 4. ALTERED NUTRITION A/O FLUID STATUS Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient will maintain highest degree of nutrition/fluid balance possible. LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated A. Dehydration R. Dysphasia 1. Explain pathophysiology of altered status R = Resolved B. Ascites G. Anorexia 2. Encourage smaller, more frequent feedings P = Potential C. Edema H. Decreased intake 3. Encourage use of supplements D. Obesity I. Nausea 4. Teach patient/family about antiemetics when ordered E. Vomiting J. Other 5. Evaluate hydration status and discuss alternatives 4. Evaluation: 5. ALTERATION IN BOWEL A/O URINARY ELIMINATION Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Bowel a/o bladder emptied adequately and complication prevented/minimized. LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated A. Constipation E. Dysuria 1. Explain pathophysiology of altered status R = Resolved B. Incontinence F. Retention 2. Encourage stool softeners unless pt. having diarrhea P = Potential C. Diarrhea G. Foley catheter 3. Monitor for signs and symptoms of UTI D. Frequency H. Other: 4. Teach Foley catheter care 5. Evaluation: 6. IMPAIRED SKIN INTEGRITY Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Skin lesions minimized and complications prevented. LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated A. Wounds R. Venous access 1. Assess skin integrity R = Resolved B. Lesions device 2. Encourage frequent turning as much as possible P = Potential C. Infections G. Other 3. Treatment D. Inflammations 4. Teach family E. Dermal ulcers 5. Assess signs and symptoms of infection 6. Evaluation:

Page 3: Initial Palliative Care Plan - ccmcks.org Palliative... · ALTERATION IN COMFORT ... Initial Palliative Care Plan ( ) Revised 02/21/05 csc Page 2 of 7 MEADOWLARK HOSPICE 709 Liberty,

Initial Palliative Care Plan ( )

Revised 02/21/05 csc Page 3 of 7

MEADOWLARK HOSPICE

709 Liberty, Clay Center KS 67432 Phone: (785) 632-2225 Fax: (785) 632-3557

7. INEFFECTIVE AIRWAY CLEARANCE A/O IMPAIRED GAS EXCHANGE Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Symptoms of respiratory distress will be decreased. LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated A. Dyspnea D. Anxiety 1. Assess lung sounds R = Resolved B. Cough E. Sleep disturbance 2. Teach family to elevate head of the bed P = Potential C. Orthopnea F. Other 3. Teach family regarding oxygen administration 7. Evaluation: 8. IMPAIRED MOBILITY Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Conservation of energy for desired activities and secured safe environment. LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated A. Weakness 1. Assess specific functional limitation/level of R = Resolved B. Vertigo impairment P = Potential C. Impairment of dexterity/activity/coordination 2. Assess safety needs, skin condition D. Alteration in ability to perform ADL’s/personal care 3. Teach positioning, turning, skin care, and personal care 4. Teach use of assistive devices (e.g. cane, etc.) 8. Evaluation: 9. ALTERATION IN CARDIAC OUTPUT Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient will maintain highest degree of cardiac output as allowed by terminal illness. LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated A. Altered myocardial contractility/intotropic changes 1. Auscultate apical pulse assessing heart rate/ R = Resolved B. Alteration in rate, rhythm, electrical conduction rhythm P = Potential C. Structural changes (e.g. valvular defects, 2. Monitor blood pressure ventricular aneurysm, etc.) 3. Inspect skin for pallor, cyanosis, diaphoresis D. Edema 4. Monitor urine output and color 5. Encourage rest periods 6. Teach proper administration of medications as ordered by physician 7. Explain pathophysiology of altered status 9. Evaluation: 10. OTHER: Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: LEGEND NURSING DIAGNOSIS LEGEND PLANS LEGEND I = Initiated R = Resolved P = Potential 10. Evaluation:

aaaaNurse signature aaaaDate

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Initial Palliative Care Plan ( )

Revised 02/21/05 csc Page 4 of 7

MEADOWLARK HOSPICE

709 Liberty, Clay Center KS 67432 Phone: (785) 632-2225 Fax: (785) 632-3557

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Page 5: Initial Palliative Care Plan - ccmcks.org Palliative... · ALTERATION IN COMFORT ... Initial Palliative Care Plan ( ) Revised 02/21/05 csc Page 2 of 7 MEADOWLARK HOSPICE 709 Liberty,

Initial Palliative Care Plan ( )

Revised 02/21/05 csc Page 5 of 7

MEADOWLARK HOSPICE

709 Liberty, Clay Center KS 67432 Phone: (785) 632-2225 Fax: (785) 632-3557

11. PSYCHOSOCIAL DISTRESS RELATED TO LOSS Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal:. Patient/family address and resolve issues surrounding psychosocial distress. LEGEND SOCIAL WORKER LEGEND PLANS LEGEND I = Initiated A. Loss of home/environment 1. Social Worker will provide counseling to R = Resolved B. Loss of cognitive abilities resolve identified issues P = Potential C. Loss of family/friends 2. Social Worker will make referrals to E. Recent diagnosis and terminal prognosis appropriate community resources F. Other: 11. Evaluation: 12. PSYCHOSOCIAL DISTRESS RELATED TO FINANCIALS Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient/family address and resolve issues surrounding psychosocial distress. LEGEND SOCIAL WORKER LEGEND PLANS LEGEND I = Initiated A. Financials 1. Social Worker will provide counseling to R = Resolved B. SRS referral resolve identified issues P = Potential C. Disability referral 2. Social Worker will make referrals to D. Loss of cognitive abilities appropriate community resources E. Other: 12. Evaluation: 13. PSYCHOSOCIAL DISTRESS RELATED TO ADVANCED DIRECTIVES Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient/family address and resolve issues surrounding psychosocial distress. LEGEND SOCIAL WORKER LEGEND PLANS LEGEND I = Initiated A. Living Will 1. Social Worker will provide counseling to R = Resolved B. Durable Power of Attorney for health care decision resolve identified issues P = Potential C. DNR 2. Social Worker will make referrals to D. Other: appropriate community resources 13. Evaluation: 14. PSYCHOSOCIAL DISTRESS RELATED TO RESOURCE LINKAGE Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient/family address and resolve issues surrounding psychosocial distress. LEGEND SOCIAL WORKER LEGEND PLANS LEGEND I = Initiated A. Meals on Wheels E. Life Line 1. Social Worker will provide counseling to R = Resolved B. Homemaking F. Legal assistance resolve identified issues P = Potential C. Private duty care G. Transportation 2. Social Worker will make referrals to D. Nursing home placement H. Other: appropriate community resources 14. Evaluation:

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Initial Palliative Care Plan ( )

Revised 02/21/05 csc Page 6 of 7

MEADOWLARK HOSPICE

709 Liberty, Clay Center KS 67432 Phone: (785) 632-2225 Fax: (785) 632-3557

15. PSYCHOSOCIAL DISTRESS RELATED TO CAREGIVER ISSUES Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient/family address and resolve issues surrounding psychosocial distress. LEGEND SOCIAL WORKER LEGEND PLANS LEGEND I = Initiated A. No caregiver in the F. Complicated family 1. Social Worker will provide counseling to R = Resolved home dynamics resolve identified issues P = Potential B. Hired caregiver(s) G. Conflict/estrangement 2. Social Worker will make referrals to C. Abuse/neglect issues H. Children in the home appropriate community resources D. Education materials I. Substance abuse issues required J. Other: 15. Evaluation: 16. PSYCHOSOCIAL DISTRESS RELATED TO: Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient/family address and resolve issues surrounding psychosocial distress. LEGEND SOCIAL WORKER LEGEND PLANS LEGEND I = Initiated A. Psychosocial diagnosis D. Depression 1. Social Worker will provide counseling to R = Resolved B. Suicidal/homicidal E. Denial resolve identified issues P = Potential ideation F. Other 2. Social Worker will make referrals to C. Substance abuse appropriate community resources 16. Evaluation: 17. SPIRITUAL DISTRESS RELATED TO: Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: Patient/family address and resolve spiritual issues. LEGEND HOSPICE CHAPLAIN LEGEND PLANS LEGEND I = Initiated A. Shame and guilt E. Funeral 1. Hospice Chaplain will provide spiritual R = Resolved B. Fear F. Spiritual support counseling and support P = Potential C. Spiritual estrangement G. Other: D. Family concern 17. Evaluation: 18. SOCIAL/ENVIRONMENTAL SUPPORT RELATED TO: Frequency: With every visit Discipline: Doctor, Nursing, Social Work, Volunteer, Pastoral Care Goal: To meet identified volunteer needs. LEGEND VOLUNTEER LEGEND PLANS LEGEND I = Initiated A. Caregiver relief D. Transportation 1. Social worker will address safety issues and R = Resolved B. Visitation E. Emergency storm plan review storm evacuation plans P = Potential C. Errands F. Home safety 2. Volunteer matched to provide support services 18. Evaluation:

aSocial Worker signature aDate

Page 7: Initial Palliative Care Plan - ccmcks.org Palliative... · ALTERATION IN COMFORT ... Initial Palliative Care Plan ( ) Revised 02/21/05 csc Page 2 of 7 MEADOWLARK HOSPICE 709 Liberty,

Initial Palliative Care Plan ( )

Revised 02/21/05 csc Page 7 of 7

MEADOWLARK HOSPICE

709 Liberty, Clay Center KS 67432 Phone: (785) 632-2225 Fax: (785) 632-3557