schwartzberg, glotia.pdf

Care Plan Activity Report

Selection: Building: RP Building; Unit: Unit R6; Status: Active

Palisade Nursing Home

System/Facility ID:DOB:

Unit-Room-Bed:Resident: RP6 - 604 - W

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Schwartzberg, Gloria

3/21/1929 (86 y)

Generated by Antony, Alex on 4/17/2015 at 12:00 pm of 33

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SENSORY DEFICIT: Visual Deficit

Resident is at risk for injury and decreased participation in leisure activities dueto visual deficit due to (specify)eyeglasses

Catipay, Karren G ActiveEffective: 1/23/2015

Problem Entered By Status / Date

Use glasses as recommended. Short-term ActiveEffective: 1/23/2015Review: 4/23/2015

Goals Type Status / Date

Ensure pathways are clear and free of clutter. Activities, Dietary, Nursing, Occupational Therapy, Physical Therapy, Social Services, Speech Therapy

ActiveEffective: 1/23/2015

Ensure call bell is always within reach of resident and easily accessible Nursing ActiveEffective: 1/23/2015

Encourage to ask for assistance as needed. Activities, Dietary, Medical, Nursing, Occupational Therapy, Physical Therapy, Social Services, Speech Therapy


Interventions Disciplines Status / Date

No notes exist for this problem.






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ASSISTANCE REQUIRED IN PERFORMING ADLs

[ x ]Eating[ x ]Bed Mobility[ x ]Transfers[ x ]Dressing[x ]Grooming[ x ]Personal Hygiene[ x ]Locomotion on unit[ x ]Locomotion off unit[ x ]Bathing[ x ]Toilet Use[ ]AmbulationAs Related To:[ ] Altered 02 supply and demand[ ] Altered mood state[ ] Anxiety[ ] Amputation[ ] Coma[ ] Contractures[ ] Fatigue/Weakness[ ] Hemiplegia/ Hemiparesis[x ] Impaired balance/coordination[ ] impaired cognition[ ] Impaired judgment/safety[ ] Medications[ ] Incomplete performance[ ] Limited ROM (specify)[ ] Pain[ ] Perceptual/ sensory impairment[ ] Performs tasks but slowly[ ] Quadriplegic[ ] Resistance to assistance[ ] Unstable or deteriorating condition/ disease



Resident will remain clean, neat, dressed appropriately for the season and free of body odor daily

Long-term ActiveEffective: 1/23/2015Review: 4/23/2015

Resident will be safe and free from accident/injury Long-term ActiveEffective: 1/23/2015Review: 4/23/2015







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Provide assistance with LOCOMOTION off UNIT[x ]Total [ ]Extensive [ ]Limited Assist [ ]Supervision[x ]One Assist [ ]Two Assist [ ]Assistive Device used

Medical, Nursing


Provide assistance with BED MOBILITY[x ]Total [ ]Extensive [ ]Limited Assist [ ]Supervision[ ]One Assist [ x]Two Assist[ ]Upper siderails to enhance bed mobility

Nursing, Occupational Therapy, Physical Therapy, Speech Therapy


Provide assistance with EATING:[ ]Total [x ]Extensive Assistance [ ]Limited Assistance [ ]Supervision[ ]Tray Setup [x ]One Assist [ ]Two Assist [ ]Adaptive/Assistive Device Used:

Dietary, Medical, Nursing, Occupational Therapy, Speech Therapy


Provide assistance with LOCOMOTION on UNIT[x ]Total [ ]Extensive [ ]Limited Assist [ ]Supervision[x ]One Assist [ ]Two Assist [ ]Assistive Device used

Activities, Audiology, Dietary, Medical, Nursing, Occupational Therapy, Physical Therapy, Social Services, Speech Therapy


Provide assistance with GROOMING/PERSONAL HYGIENE[ ]Total [ x]Extensive [ ]Limited Assist [ ]Supervision[x ]One Assist [ ]Two Assist

Nursing, Occupational Therapy


Provide assistance with DRESSING[ ]Total [x ]Extensive [ ]Limited Assist [ ]Supervision:[x ]One Assist [ ]Two Assist [ ]Assistive Device used:

Nursing, Occupational Therapy, Physical Therapy


Provide assistance with TRANSFERS[ x]Total [ ]Extensive [ ]Limited Assist [ ]Supervision[ ]One Assist [x ]Two Assist[x ]Mechanical Lift

Nursing, Occupational Therapy, Physical Therapy








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Obtain OT eval completed 1/24/15 & provide 18" w/c with elite gel cushion Occupational Therapy


Encourage participation in ADL care Activities, Audiology, Dietary, Medical, Nursing, Occupational Therapy, Physical Therapy, Social Services, Speech Therapy


PT/OT eval completed; services started 1/24/2015; PT/OT d/c 3/23/15 Occupational Therapy, Physical Therapy


Praise and provide positive reinforcement for completed task Activities, Audiology, Dietary, Medical, Nursing, Occupational Therapy, Physical Therapy, Social Services, Speech Therapy


Provide assistance with BATHING[x ]Total [ ]Extensive [ ]Limited Assist [ ]Supervision[ ]One Assist [x ]Two Assist



Provide assistance with TOILET USE[x ]Total [ ]Extensive [ ]Limited Assist [ ]Supervision[ ]One Assist [x ]Two Assist










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ELIMINATION: Altered Exit Urine/Stool

Alteration in elimination

As evidenced by:[ ] External urinary catheter[ x ] Indwelling urinary catheter[ ] Intermittent urinary catheter[ ] Suprapubic catheter[ ] Urostomy[ ] Colostomy[ ] Ileostomy

Related to:[ ] Medical Condition (specify)[ ] Pressure Ulcer



Resident will show no signs of obstruction as evidenced by adequate urine output, no abdominal distention, and no abdominal discomfort.



Provide catheter care as per protocol Nursing ActiveEffective: 1/23/2015

Monitor catheter for occlusion / obstruction. Nursing ActiveEffective: 1/23/2015

Lubricate skin every shift and PRN. Nursing ActiveEffective: 1/23/2015

Monitor for signs/symptoms of UTI (e.g., change in color, amount, odor, clarity) and report to physician.

Nursing ActiveEffective: 1/23/2015








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Mood State/Psychosocial Wellbeing

Altered psychosocial wellbeing/mood state of feelings as manifested asevidenced by:[ X ] Signs of sadness[ ] Reduced social interaction[ ] Restlessness[ ] Unpleasant mood in the morning[X ] Apprehensiveness[ ] Difficulty falling asleep[ ] Staying asleep[ ] Conflict with staff and/or family[ X ] Express strong ID & feelings over lost roles/status[ ] Unhappy w/peers and/or roommate[ ] Repetitive Q's, verbalizations, complaints

Rutigliano, MSW, Care Mgr, Ashley



Promote sense of wellbeing and self esteem, as evidenced by increased involvement in daily community life.

Short-term ActiveEffective: 1/24/2015Review: 6/23/2015

Identify feelings and concerns through staff support Short-term ActiveEffective: 1/24/2015Review: 6/23/2015

Build coping skills with regard to life situation - losses Short-term ActiveEffective: 1/24/2015Review: 6/23/2015

Promote sense of wellbeing in compensating for dementia related mood disorder, as evidenced by decreased episodes of agitated - disruptive behavior



Address sleep pattern disturbances Activities, Dietary, Medical, Nursing, Social Services


Allow for right to privacy Activities, Dietary, Medical, Nursing, Social Services


Acknowledge behavior as an attempt to communicate needs - feelings Activities, Dietary, Medical, Nursing, Social Services








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Assist resident with acceptance of losses Activities, Dietary, Medical, Nursing, Social Services


Arrange for interpreter - alternate means to communicate. Activities, Dietary, Medical, Nursing, Social Services


Anticipate needs, reassure, and provide secure setting Activities, Dietary, Medical, Nursing, Social Services


Encourage decision making - control - independence within limitations Activities, Dietary, Medical, Nursing, Social Services


Orient to new situations and encourage integration into community life Activities, Dietary, Medical, Nursing, Social Services


Encourage verbalization of concerns and feelings Activities, Dietary, Medical, Nursing, Social Services


Monitor relationship with roommate, peers and staff Activities, Dietary, Medical, Nursing, Social Services


Explain all care, and promote resident trust in caregivers. Activities, Dietary, Medical, Nursing, Social Services


Engage in therapeutic and ADL activities which support self-esteem Activities, Dietary, Medical, Nursing, Social Services








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Provide individual - group counseling Activities, Dietary, Medical, Nursing, Social Services


Recognize - explore use of positive coping skills and strengths Activities, Dietary, Medical, Nursing, Social Services


Resident / family advised of potential for resident's room and / or roommate, to be changed, at any time throughout the stay.

Nursing, Social Services


Provide antidepressant - antianxiety - hypnotic as ordered, referral to psychiatrist - psychologist as indicated.

Activities, Dietary, Medical, Nursing, Social Services


Encourage family contact - support Activities, Dietary, Medical, Nursing, Social Services



POC updated and reviewed,continue with current POC. Cury, MSW, HannahCreated On: 3/25/2015

Notes Status / Date






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FALLS

Resident / Patient is at risk for injury or falls:

As Evidenced by:

[ x ] Fell in the last 30 days[ ] Fell in the last 31-180 days[ ] Hip or other injury in the last 180 days[ ] Fell prior to admission

Related to:

[ ] Amputation[ ] Contractures[ ] Dizziness[ ] Easily fatigued[ ] Hemiplegia/Paresis[ ] Impaired balance[ ] Impaired decision making[ ] Impaired hearing[ ] Impaired physical mobility[ ] Impaired vision[ ] Incontinence[ ] Medications[ ] New environment[ ] Pain[ ] Problem behavior/ Noncompliant[ ] Quadriplegia[ ] Resists assist with ADL[ ] Unstable medical condition[ ] Unsteady gait[ ] Use of assistive device[ ] Use of visual aids[ ] Wandering



Resident will be free of falls. Short-term ActiveEffective: 1/23/2015Review: 4/23/2015







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Monitor for othostatic hypotension Medical, Nursing, Physical Therapy


Assure adequate time for resident to complete tasks Nursing ActiveEffective: 1/23/2015

Encourage use of glasses Nursing ActiveEffective: 1/23/2015

PT/OT eval completed; services started 1/24/2015; PT/OT d/c 3/23/15 Occupational Therapy, Physical Therapy


Ensure that call bell is within easy reach at all times. Activities, Nursing, Occupational Therapy, Physical Therapy, Social Services, Speech Therapy


Anticipate resident needs with regard to ADLs. Activities, Nursing, Occupational Therapy, Physical Therapy


Provide education on safety techniques. Nursing, Occupational Therapy, Physical Therapy









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DIABETES MELLITUS: IDDM / NIDDM

Resident has:

[ x] Diagnosis of Diabetes Mellitus[ ] Elevated blood glucose level



Resident will demonstrate a blood glucose level within normal limits Long-term ActiveEffective: 1/23/2015Review: 4/23/2015


Monitor for observable signs and symptoms of hyperglycemia or hypoglycemia. Activities, Dietary, Medical, Nursing, Social Services


Administer medications as ordered. Nursing ActiveEffective: 1/23/2015

Monitor blood glucose level as ordered. Dietary, Medical, Nursing









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3/21/1929 (86 y)


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DIABETES MELLITUS: IDDM / NIDDM

Resident has:

X[ ] Diagnosis of Diabetes Mellitus[ ] Elevated blood glucose level

Aronoff, Shifra ActiveEffective: 1/24/2015


Resident will be free of observable signs and symptoms of hyper- and hypo-glycemia. Long-term ActiveEffective: 1/24/2015Review: 6/21/2015


Implement diet as ordered (specify) NCS Activities, Dietary, Medical, Nursing


Plan and implement nutrition/diet teaching program for resident and family/significant others.

Dietary, Nursing


Provide positive reinforcement for compliant behavior with dietary restrictions. Activities, Dietary, Medical, Nursing


Monitor for observable signs and symptoms of hyperglycemia or hypoglycemia. Activities, Dietary, Medical, Nursing, Social Services


Monitor blood glucose level as ordered. Dietary, Medical, Nursing



CCPs reviewed and updated. Continue w/ POC. Lowy, AlisonCreated On: 2/24/2015

Notes Status / Date






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DENTAL CARE: At Risk for Impairment

At high risk for impairment of oral or dental condition related to (specify): fullupper dentures

As evidenced by:[ ] Cracked / dry lips[ ] Inflamed gums[ ] Pain[ ] Mouth ulcers[ ] Swollen tongue[ ] Broken / loose / carious teeth[x ] Has dentures or removable bridge[ ] Some / all natural teeth lost[ ] Does not have or does not wear dentures

Related to:[ ] Chemotherapy[ ] Dehydration[ ] Impaired cognition[ ] Medications[ ] Periodontal disease[ ] Poor circulation[ ] Resists mouth care



Resident / Patient will be able to chew food without discomfort. Short-term ActiveEffective: 1/23/2015Review: 4/23/2015







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PAIN MANAGEMENT

Alteration in comfort: Pain related to (specify type, location and characteristicsthereof): R hip incision



Resident/patient will verbalize adequate pain relief in order to achieve participation in ADLs.



Assist with or provide oral hygiene daily to prevent infection and cavities. Nursing ActiveEffective: 1/23/2015

Administer medications or treatments as ordered by physician. Medical, Nursing, Pharmacy


Provide denture care Nursing ActiveEffective: 1/23/2015

Assess chewing / swallowing ability. Dietary, Medical, Nursing, Speech Therapy


Assess risk factors on an ongoing basis Dietary, Medical, Nursing, Speech Therapy









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Administer medications as ordered by MD. Medical, Nursing, Occupational Therapy, Pharmacy


Monitor behavior and assess for pain/discomfort if change in behavior is noted. Medical, Nursing


Promote proper body alignment Nursing, Physical Therapy


Monitor side effects and adverse reactions resulting from interventions rendered. Medical, Nursing, Occupational Therapy, Physical Therapy, Respiratory Therapy


On-going assessment of the resident's/patient's pain with emphasis on the onset, location, description, intensity of pain and alleviating and aggravating factors.

Medical, Nursing, Occupational Therapy, Physical Therapy









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ADVANCE DIRECTIVES

Potential for resident's wishes not being adhered to regarding advancedirectives.




Insures that residents' rights regarding advance directives are reviewed and that residents' medical care and treatment wishes are implemented as directed.



If indicated, write DNR order Medical ActiveEffective: 1/24/2015

On admission, review advance directives Medical, Nursing, Social Services


If indicated, insure ID bracelet reflects DNR Nursing ActiveEffective: 1/24/2015

Review advance directive options with resident/family/proxy annually, s/p significant change, and as requested by resident/family/proxy/team.

Medical, Nursing, Social Services


Document in interdisciplinary section of chart re: advance directive status Social Services


Insure paperwork and appropriate sticker for advance directive(s) in place in chart Nursing ActiveEffective: 1/24/2015



Notes Status / Date






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ANTICOAGULATION THERAPY: Medication Use

Resident is on an anticoagulation therapy of (specify): Lovenox



Resident will have no signs of abnormal bleeding. Short-term ActiveEffective: 1/23/2015Review: 4/23/2015


Teach resident to report bleeding gums, blood in stool, blood in sputum to nurse or physician.


Skin check every shift. Nursing ActiveEffective: 1/23/2015

Report for any changes of in skin condition (e.g., discoloration, ecchymosis), signs of abnormal bleeding, or side effects of medication to physician.


Assess for signs of abnormal bleeding (e.g., monitor for signs symptoms such as hematuria, bleeding gums, tarry stools, petechiae, etc.).


Administer anticoagulant therapy as per MD order. Nursing ActiveEffective: 1/23/2015

Avoid bumping and handle resident gently when providing hands on care. Nursing ActiveEffective: 1/23/2015








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CARDIAC DISEASES: Hypertension

At high risk for injury related to cardiovascular complications of Hypertension.



Resident/patient will maintain Blood Pressure within normal limits. Long-term ActiveEffective: 1/23/2015Review: 4/23/2015


Monitor for adverse reactions of antihypertensive medications such as dizziness or orthostatic hypotension


Educate resident on symptoms of high blood pressure such as headache, weakness, muscle cramp, tingling, palpitations, sweating, and vision disturbances.

Medical, Nursing


Administer antihypertensive medication(s) as prescribed by MD. Medical, Nursing, Pharmacy


Monitor vital signs and BP as ordered by MD. Medical, Nursing









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ELIMINATION: Bowel Incontinence

Resident is incontinent of bowel requiring incontinent care.

As related to:[ ] Impaired cognition[ x ] Impaired mobility[ ] Impaired sphincter control[ ] Infection[ ] Sensory impairment[ ] Other



Resident will be free of skin breakdown secondary to incontinence. Long-term ActiveEffective: 1/23/2015Review: 4/23/2015


Maintain toileting schedule(specify): Nursing ActiveEffective: 1/23/2015


Monitor redness or broken areas during toileting/diaper change every 2 - 4 hours. Nursing ActiveEffective: 1/23/2015

Maintain toileting schedule(specify):q2h Nursing ActiveEffective: 1/23/2015








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ELIMINATION: Constipation

Alteration in elimination related to constipationAs evidenced by:[ ] Complaints of rectal pressure[ ] Decreased appetite[ ] Decreased bowel sounds[ ] Dry stool[ ] Enema use[ ] Impaction[ ] Infrequent stools[ ] Nausea[ ] Oozing of stool[x ] Straining of stool[ ] Toileting plan[ ] Other

Related to:[ ] Aging process[ ] Altered neuromuscular function[ ] Chemotherapy[ ] Coma[ ] Poor dietary intake[ ] Immobility[ ] Medication use[ ] Poor fluid intake[ ] Other



Resident will have bowel movement once at least every 3 days. Long-term ActiveEffective: 1/23/2015Review: 4/23/2015







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Encourage fluid intake as medically appropriate. Activities, Dietary, Nursing, Occupational Therapy, Physical Therapy, Social Services, Speech Therapy


Maintain toileting schedule specific to the resident. Nursing ActiveEffective: 1/23/2015

Administer laxatives/bowel medications as ordered Medical, Nursing



Report to physician if no bowel movement in 3 days. Nursing ActiveEffective: 1/23/2015








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MUSCULOSKELETAL DISORDER: Total Hip Replacement

Resident / Patient had a Total Hip Replacement secondary to (specify): R hip



Resident / Patient will perform ADL's per restorative program Short-term ActiveEffective: 1/23/2015Review: 4/23/2015

Resident / Patient will have pain controlled Short-term ActiveEffective: 1/23/2015Review: 4/23/2015


Monitor respiratory status for change in lung sounds, shortness of breath, and increased respiratory rate.

Medical, Nursing


Monitor for pain/discomfort and medicate as needed. Medical, Nursing


Monitor for increased edema, redness or warmth in affected extremity Medical, Nursing


Monitor vital signs Medical, Nursing


Monitor skin for red or open areas. Nursing ActiveEffective: 1/23/2015

Monitor surgical site for increased redness, warmth, edema or drainage. Medical, Nursing


Monitor incision for approximation of wound. Medical, Nursing









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NUTRITIONAL STATUS: Risk for Weight Loss/Unplanned Weight Loss

Resident is at risk for weight loss

As evidenced by:[ ] significant weight loss[ ] leaves 25% or more of meals[ ] nutritional deficit

As related to:[ ] altered taste[ ] behavioral problem[ ] chewing problem[ ] food preference[ ] impaired cognition[ ] inability to feed self[ ] mental / emotional problem[ ] mouth pain[ ] pain[ ] resists eating / being fed[ ] swallow problems[ ] tires during eating[X ] DX of femur fx, HTN and DM



Resident will maintain optimal nutrition as evidenced by stable weight.Specify: 170-180 lbs








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Monitor and record food intake at each meal. Nursing ActiveEffective: 1/24/2015

Notify MD when weight loss occurs Dietary, Nursing


Offer food substitutes or cater to food preferences as requested or as indicated. Dietary, Nursing


Review labs as ordered Dietary, Medical, Nursing


Monitor weights specify: Weekly Dietary, Medical, Nursing


Provide assistance as needed with meals Nursing ActiveEffective: 1/24/2015

Provide pleasant environment for meals Dietary, Nursing


Minimize distractions during meals Dietary, Nursing, Speech Therapy




Notes Status / Date






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NUTRITIONAL STATUS: Therapeutic Diet

Resident is on a Therapeutic Diet secondary to:[X ] HTN[ ] CHF[ ] CKD[ ] Edema[ ] Lactose intolerance[ ] Gluten intolerance[ ] Constipation[ ] Other _______________



Resident to adhere to therapeutic diet regimen Long-term ActiveEffective: 1/24/2015Review: 6/21/2015


Review labs as ordered. Dietary, Nursing


Offer food substitutes or cater to food preferences as requested or indicated. Activities, Dietary, Nursing, Speech Therapy


Monitor intake and assess appetite Dietary, Nursing


Assess efficacy of diet quarterly and as needed. Dietary, Medical


Provide diet per MD order. (specify) HSR Activities, Dietary, Medical, Nursing




Notes Status / Date






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DEHYDRATION: Potential Fluid Volume Deficit

[ ] Fluid volume deficit related to (specify):___________________

As evidenced by:[ ] Weight Loss

Related to:

[ ] Diuretic Therapy[ ] Dysphagia[ ] Diagnosis of Dementia[ ] Diagnosis of Depression[ ] Diagnosis of Infection[X ] Other: h/o HTN



Resident will not develop complications related to fluid volume deficit. Long-term ActiveEffective: 1/24/2015Review: 6/21/2015


Encourage 2550_mL's fluid per day. Dietary, Medical, Nursing


Monitor for signs/symptoms of dehydration such as change in mental status, dry oral mucosa, decreased output, tenting of skin, etc.

Dietary, Medical, Nursing


Monitor lab values as ordered to monitor for impending signs of dehydration. Dietary, Medical, Nursing


Encourage PO fluids. Activities, Dietary, Medical, Nursing




Notes Status / Date







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ACTIVITIES: At Risk for Impaired Social Interaction

As evidenced by:[ ]Activity pursuits altered:[ ]Agitated behavior[ ]Anxious behavior[ ]Declines invitations to activity programs[ ]Decreased ability to initiate activity participation[ ]Decreased response to stimuli[ ]Disruptive behavior[ ]Impaired attention span[ ]Inappropriate behavior[ ]Interpersonal conflicts[ ]Need for guidance during group activities[ ]Need for reminders[ ]Periodic anxious behavior[ ]Periodic Sad Affect[ ]Physically aggressive behavior[ ]Resists leaving neighborhood[ ]Resists leaving room[ ]Restlessness[x ]Sad Affect[ ]Self-directed behavior with regards to activity pursuits[ ]Self-initiated participation during group activity programs[ ]Sleeping during group programs[ ]Unrealistic expectations[ ]Verbally aggressive behavior[x ]Verbalizes desire for self-directed behavior with regards to activity pursuits

Related to:[ ] Bed rest[ ] Impaired Cognition[ ] Impaired Communication[ ] Impaired Hearing[ x ] Impaired Physical Mobility[ ] Impaired Vision[ ] Intellectual Disability/Developmental Delay[ ] Irregular sleep pattern[ ] Limited time awake[ ] Loss/grief[x ] Mood State[ ] New to neighborhood[ ] New admission[ x ] Pain[ ] Primary language other than English[ ] Short-term stay[ ] Wandering[ ] Other (specify):

Ellison, Jeanette Dunn ActiveEffective: 1/26/2015






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[ ] Develop / [ x ] Maintain activity routine through daily pursuit of choices to support/promote independence.


[ x ] Maintain / [ ] Increase present level of socialization and leisure interests throughparticipation in activities of choice such as (specify):•concert•reading(books/magazine•special evisitsAt least[ x ] 1-2 times per week[ ] 3-4 times per weekto support/promote functioning/independence



Describe activities available, and assist resident in choosing activities that match their interests and abilities.



Offer supplies/materials as needed. Activities, Dietary, Medical, Nursing, Social Services


Provide opportunities for social interaction as tolerated. Activities, Dietary, Medical, Nursing, Social Services


Provide social/emotional support. Activities, Dietary, Medical, Nursing, Social Services


Respect resident's right to refuse to participate/attend therapeutic, recreational, social and/or spiritual programs.



Provide monthly activity calendars. Activities, Dietary, Medical, Nursing, Social Services








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Provide friendly visits as needed Activities, Dietary, Medical, Nursing, Social Services


Provide Therapeutic Activities Information packet. Activities, Admissions, Nursing, Social Services


Encourage activities to help maintain comfort such as (specify:)•concert•reading)books/magazine•on/off unit programs




Care plan reviewed, updated and ongoing. Schechter, AliCreated On: 4/01/2015

Care plan review updated and ongoing continue with plan of care. Ellison, Jeanette DunnCreated On: 2/26/2015

Notes Status / Date

SKIN INTEGRITY: At Risk for Skin Breakdown

At high risk for skin breakdown related to Braden Scale Score, decreasedmobility, incontinence, edema, anemia, or malnourishment.

Tudor, RN, Barbara A ActiveEffective: 2/26/2015


Resident will maintain intact skin. Long-term ActiveEffective: 2/26/2015Review: 5/27/2015


Complete pressure ulcer risk assessment (Braden Scale) and review quarterly and PRN. Dietary, Nursing


Provide incontinent care as needed. Nursing ActiveEffective: 2/26/2015

Maintain turning and positioning schedule as recommended Q2H & prn Medical, Nursing, Occupational Therapy, Physical Therapy








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Off load heels when in bed. Nursing, Physical Therapy


Position resident at 30 degree lateral position (Low to Semi-Fowler's) when in bed, as tolerated.


Monitor weight for significant changes. Nursing ActiveEffective: 2/26/2015

Encourage fluid intake Dietary, Medical, Nursing


Ensure that gentle handling of resident is provided at all times. Activities, Nursing, Occupational Therapy, Physical Therapy


Prevent friction during transfers, resident care and bed mobility. Nursing, Occupational Therapy, Physical Therapy


Monitor lab values as ordered and report/ treat abnormalities Dietary, Nursing


Use skin protectant / skin barrier when performing perineal care. Nursing ActiveEffective: 2/26/2015

Dietitian consult prn Dietary, Medical, Nursing


Encourage adequate nutrition. Activities, Dietary, Medical, Nursing, Occupational Therapy, Social Services, Speech Therapy









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SENSORY DEFICIT: Hearing Deficit

Altered ability to hear speech/environmental cues secondary to sensory deficit

Capozzelli, Mary ActiveEffective: 3/27/2015


Resident will be a social participant despite hearing loss as evidenced by participation in leisure activities of choice.


Resident will demonstrate the receipt of the speech sound signal as evidenced by appropriate responses to communication exchange.



DISCHARGE PLANNING-Long Term

Staff believes resident has no potential for D/C @ this time, enable LOA.




Reside in the least restrictive and most supportive environment. Long-term ActiveEffective: 3/10/2015Review: 6/08/2015


Enable leaves of absence (LOA's) per resident request/need, and with physician justification for continued long-term placement.



Regularly assess the resident's potential for discharge. Activities, Dietary, Medical, Nursing, Social Services


Consult with resident/family re: desire to return to community. Activities, Dietary, Medical, Nursing, Social Services




Notes Status / Date






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Sit resident close to front of activity or next to facilitator to aid with hearing and comprehension.



Provide visual cues to assist with understanding. Activities, Audiology, Dietary, Medical, Nursing, Occupational Therapy, Physical Therapy, Social Services, Speech Therapy


Approach resident from front and focus resident's attention prior to speaking, using gentle touch as needed. Speak slowly, clearly, using a slightly louder voice. Ask resident to recap what was said to confirm understanding. Allow more time to respond









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Repeat communication using different words to ensure understanding and use visual cues as needed





schwartzberg, glotia.pdf

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