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1 HOME HEALTH AIDE CARE PLAN PLAN DE CUIDADO DE LA AYUDANTE DE ENFERMERA Patient Address: Telephone No. Directions to Home: Care Manager: Frequency/Duration: Supervisory visits: every 14 days every 30 every 60 Patient problem: Other Phone No. PARAMETERS TO NOTIFY CARE MANAGER / PARAMETROS A NOTIFICAR To BP P R Urine Other (pain) DNR: Yes No PRECAUTIONARY AND OTHER PERTINENT INFORMATION - Check all that apply. Circle the appropriate item if separated by slash. Lives alone/vive solo Non weight bearing/no soporte de peso: R L Dentures/Dentaduras: Upper/Sup. Lower/baja Lives with other/vive con otros Fall precautions/prevención de caidas Partial/Parcial Alone during the day/solo durante el día Special equipment/equipos especiales: Oriented/Orientado x 3 Alert/Alerta Bed bound/confinado a la cama Forgetful/Confused-Olvidadiso/Confuso Bed rest/brps/descanso en la cama Speech/Communication deficit/habla deficiente Urinary catheter/cateter urinario Up as tolerated/se levanta hasta donde puede Vision deficit/visión def: Glasses/Espejuelos Prosthesis/Protesis (specify): Amputee (specify)/amputación: Contacts/Lentes de contacto Other/Otro: Allergies/Alergias (specify): Partial weight bearing/soporte de peso parcial: R L Hearing deficit/def.auditiva: Hearing aid/ayuda para oir Diabetic/Diabetico Do not cut nails/no cortar uñas Diet/Dieta: Seizure precaution/precauciones con convulsiones Watch (observar por) for hyper/hypoglycemia Bleeding precautions/prec. sangreamientos Prone to fractures/posible fracturas Other (specify)/otro (especificar): Check all applicable tasks. Specify by circling the applicable activity for those items separated by slashes. Write additional precautions, instructions, etc as needed beside the appropriate item ASSIGNMENT-TAREAS VITALS / VITALES BATH / BAÑO HYGIENE /GROOMING / HIGIENE PROCEDURES / PROCEDIMIENTOS Temperature/Temperatura Pulse/Pulso Respirations/Respiración Blood Pressure/Presión Weight/Peso Pain Rating (0-10 scale)/dolor Tub/Shower-Bañera/Ducha Bath: Bed/Sponge - Baño:Cama/Sponja Partial/Complete-Parcial/Completo Assist Bath-Chair - Asistir baño en silla Personal Care/Cuidado Personal Assist with Dressing/Asistir vestirse Hair Care/Cuidado del cabello Shampoo/Champu Skin Care/Cuidado de la piel Foot Care/Cuidado de los pies Check Pressure Areas/Ulceras de presión Nail Care/Cuidado de las uñas Oral Care/Cuidado oral Clean Dentures/Limpiar dentaduras Shave/Afeitar Other/Otro: Assist with Elimination/Asistir eliminación Catheter Care/Cuidado de catetes Ostomy Care/Cuidar ostomia Record Intake/Output-Registro tomar/salida Inspect/ Reinforce/Inspeccionar Dressing/Vendas (see specifics in comment section/ver comentarios) Medication Reminder/Recordar medicinas Other (specify)/otro (especificar): Every visit Multi-Visits Weekly a day only Other - Otro Comments/Instructions Comentarios/Instrucciones ACTIVITY / ACTIVIDADES NUTRITION / NUTRICION OTHER OTHER / OTRO ASSIGNMENT-TAREAS Assist with - Asistir con Ambulation/Ambulación W/C/Walker/Cane - Silla Rueda/Andador/Baston Assist with Mobility/assistir con mibilidad Chair/Bed/Dangle-Silla/Cama/Oscilar Commode/Cuña-Pato Shower/Tub=Ducha/Bañera ROM Active/Passive-Rango de Mov.Activo/Pasivo Arm R/L (Brazos D/I) Leg R/L (Pies D/I) Positioning-Encourage / Cambio de Posiciones Assist/assistir hrs Exercise Per - Ejercicios por PT / OT / SLP Care Plan/Plan de cuidado Other (specify)/otro (especificar): Meal Preparation/Prep. de comida Assist with Feeding/Asistir alimentar Limit/Encourage-Limitar/Exigir Fluid/Fluidoss Grocery Shopping/Comprar comida Other (specify)/otro (especificar): Wash Clothes/Lavar ropa Light Housekeeping/Ligera limpieza Bedroom / Baño Bathroom/Cuarto / Kitchen /Cocina Change Bed Linen/Cambiar sábanas Equipment Care/Cuidado de equipos Other (specify)/otro (especificar): Every visit Multi-Visits Weekly a day only Other - Otro Comments/Instructions Comentarios/Instrucciones Signature/Title: Date: Review and/or revise at least every 60 days SIGNATURE/TITLE DATE SIGNATURE/TITLE DATE PART 1 - Clinical Record PATIENT NAME - Last, First, Middle Initial PART 2 - Patient Home Folder ID# HOME HEALTH AIDE CARE PLAN (855)PNSystem
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