Restorative Nursing Program Exercise Worksheet. Restorative Nursing Program Exercise #1a Pepper Mint Observation Period 9/9 9/15/14 (ARD)
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1 Restorative Nursing Program Exercise Worksheet Restorative Nursing Program Exercise #1a Pepper Mint Transmitted Value Reviewed Value Answer O0500A Passive Range of Motion 6 days O0500A Passive Range of Motion days O0500B Active Range of Motion 6 days O0500B Active Range of Motion days Restorative Nursing Program Exercise #1b Pepper Mint Observation Period 9/9 915/14 (ARD) Transmitted Value Reviewed Value Answer O0500A Passive Range of Motion 6 days O0500A Passive Range of Motion days Restorative Nursing Program Exercise #2 Chocolate Almond Transmitted Value Reviewed Value Answer O0500F Walking 7 days O0500F Walking days Restorative Nursing Program Exercise #3 Double Chocolate Almond Transmitted Value Reviewed Value Answers H0200C Scheduled Toileting Yes H0200C Scheduled Toileting M1200C Turning/Repositioning Yes M1200C Turning/Repositioning Restorative Nursing Program Exercise #4a Lemon Custard Transmitted Value Reviewed Value Answer O0500J Communication 6 days O0500J Communication days Restorative Nursing Program Exercise #4b Lemon Custard Transmitted Value Reviewed Value Answer O0500J Communication 7 days O0500J Communication days Prepared by Myers and Stauffer LC 1 DEDICATED TO GOVERNMENT HEALTH PROGRAMS
2 Restorative Nursing Program Exercise Worksheet Restorative Nursing Program Exercise #5 Bubble Gum Transmitted Values Reviewed Values Answers O0500B Active Range of Motion 7 days O0500B Active Range of Motion days O0500D Bed Mobility 7 days O0500D Bed Mobility days O0500E Transfers 7 days O0500E Transfers days O0500G Dressing or Grooming 7 days O0500G Dressing or Grooming days O0500H Eating 7 days O0500H Eating days O0500J Communication 7 days O0500J Communication days Restorative Nursing Program Exercise #6 Raspberry Sherbet Transmitted Values Reviewed Values Answers O0500A Passive Range of Motion 7 days O0500A Passive Range of Motion days O0500C Splint/Brace Assistance 7 days O0500C Splint/Brace Assistance days Restorative Nursing Program Exercise #7 Cherry Cordial Transmitted Values Reviewed Values Answer O0500B Active Range of Motion 7 days O0500B Active Range of Motion days Prepared by Myers and Stauffer LC 2 DEDICATED TO GOVERNMENT HEALTH PROGRAMS
3 Restorative Nursing Care Plan and Flow Record Month/Year: September 2014 ARD: 9/15/14 Directions: Use one form for each program. Complete and describe program, problem, measurable goals, and interventions. Be specific. Record direct restorative minutes daily in shift box. Be sure to initial when service is provided and sign form (full signature, title). A licensed nurse must evaluate the program within the quarter. Notes must be dated and signed. Program: Active/Passive Range of Motion Problem: Unable to move left side fingers, hand, arm and leg secondary to CVA and left sided hemiplegia Goal: Will remain free of contractures of left fingers, hand, arm and leg through next review/90 days Interventions: Active/Passive ROM to left fingers, hand, arm and leg; 5 reps of each joint bid daily; stop if complains of pain Restorative aide note: 9/12/14, 11:00 am. Out for MD appt this morning. Edgar Eggplant, CNA Licensed nurse evaluation of resident s response to program (Must be within the quarter): 9/15/14, 2:00 pm. Resident was out for an appointment one morning during the observation period. Has received ROM to left side fingers, hand, arm and leg, 5 reps each joint, for at least 15 minutes a day for 6 days this observation period. No complaints of pain during exercises, and no contractures. Still unable to move left side extremities. Will continue program. Olive Oliver, RN 7-3/mins 8 8 X X EE EE X EE EE CA CA CA CA EE EE EE EE CA CA CA CA EE EE EE EE CA CA CA CA EE EE EE CA CA X 3-11/mins 8 8 X X X GA GA X OO OO OO GA GA PP PP PP PP PP GA GA OO OO OO OO X GA GA GA OO OO PP PP PP GA GA X Full Signature and Title Full Signature and Title EE Edgar Eggplant, CNA CA Carmella Apple, CNA GA Gus Asparagus, CNA OO Ollie Orange, CNA PP Patty Peach, CNA Full signatures required to authenticate initials. Resident Name Medical Record Number Room Number Pepper Mint Example #1a This form is not endorsed by any state or government agency.
4 Restorative Nursing Care Plan and Flow Record Month/Year: September 2014 ARD: 9/15/14 Directions: Use one form for each program. Complete and describe program, problem, measurable goals, and interventions. Be specific. Record direct restorative minutes daily in shift box. Be sure to initial when service is provided and sign form (full signature, title). A licensed nurse must evaluate the program within the quarter. Notes must be dated and signed. Program: Passive Range of Motion Problem: Unable to move left side fingers, hand, arm and leg secondary to CVA and left sided hemiplegia Goal: Will remain free of contractures of left fingers, hand, arm and leg through next review/90 days Interventions: Passive ROM to left fingers, hand, arm and leg; 5 reps of each joint bid daily; stop if complains of pain Restorative aide note: 9/12/14, 11:00 am. Out for MD appt this morning. Edgar Eggplant, CNA Licensed nurse evaluation of resident s response to program (Must be within the quarter): 9/15/14, 2:00 pm. Resident was out for an appointment one morning during the observation period. Has received ROM to left side fingers, hand, arm and leg, 5 reps each joint, for at least 15 minutes a day for 6 days this observation period. No complaints of pain during exercises, and no contractures. Still unable to move left side extremities. Will continue program. Olive Oliver, RN 7-3/mins 8 8 X X EE EE X EE EE CA CA CA CA EE EE EE EE CA CA CA CA EE EE EE EE CA CA CA CA EE EE EE CA CA X 3-11/mins 8 8 X X X GA GA X OO OO OO GA GA PP PP PP PP PP GA GA OO OO OO OO X GA GA GA OO OO PP PP PP GA GA X Full Signature and Title Full Signature and Title EE Edgar Eggplant, CNA CA Carmella Apple, CNA GA Gus Asparagus, CNA OO Ollie Orange, CNA PP Patty Peach, CNA Full signatures required to authenticate initials. Resident Name Medical Record Number Room Number Pepper Mint Example #1b Prepared by Myers and Stauffer LC This form is not endorsed by any state or government agency.
5 Restorative Nursing Care Plan and Flow Record Month/Year: September 2014 ARD: 9/15/14 Directions: Use one form for each program. Complete and describe program, problem, measurable goals, and interventions. Be specific. Record direct restorative minutes daily in shift box. Be sure to initial when service is provided and sign form (full signature, title). A licensed nurse must evaluate the program within the quarter. Notes must be dated and signed. Program: Walk to Dine Problem: Ambulation Goal: Walk to dining room at lunch daily Interventions: Remind of meal times and how to get to dining room Evaluation: 11-7/mins 9/15/14, Continue. Olive Oliver, RN 7-3/mins X EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE EE X 3-11/mins Full Signature and Title Full Signature and Title EE Edgar Eggplant, CNA Full signatures required to authenticate initials. Resident Name Medical Record Number Room Number Chocolate Almond Example #2 This form is not endorsed by any state or government agency.
6 Restorative Nursing Program Flow Sheet Day of the Month Turn/reposition q 2 hrs when in bed 11-7 Reposition q 1 hr when in wheelchair Check on q 2 hrs during night for toileting needs and incontinent care Take to toilet upon awakening, before and after meals and at bedtime EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE C A CA CA CA CA 3-11 GA GA GA GA GA OO OO OO GA GA GA GA OO OO OO OO GA GA GA OO OO OO GA GA GA GA GA OO OO OO 7-3 EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE C A CA CA CA CA 3-11 GA GA GA GA GA OO OO OO GA GA GA GA OO OO OO OO GA GA GA OO OO OO GA GA GA GA GA OO OO OO 11-7 PP PP PP PP PP BB BB BB BB BB PP PP BB BB BB BB BB PP PP BB BB BB PP PP PP PP PP BB BB BB 7-3 EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE C A CA CA CA CA C C C C C C C C I I C C C C C C C C I I I C C C C C C C C C 3-11 C = continent all shift I = incontinent at least one time during shift I C C C C I C C C C C C I I C C C C C C C C I C I I C C C C EE GA PP Edgar Eggplant, CNA Gus Asparagus, CNA Patty Peach, CNA Full Signature and Title GA GA GA GA GA OO OO OO GA GA GA GA OO OO OO OO GA GA GA OO OO OO GA GA GA GA GA OO OO OO CA OO BB Carmella Apple, CNA Ollie Orange, CNA Brock Broccoli, LPN Full Signature and Title Resident Name: Double Chocolate Almond Month Sept Year 2014 Example #3
7 Care Plans Date Program Problem Goal Interventions 6/20/14 Scheduled Unable to toilet self due to Will remain dry during 1. Take to toilet upon awakening, Toileting being unable to find toilet waking hours daily before and after meals, at bedtime independently and unable x 90 days 2. Visual cue (large, bright picture on to voice toileting needs toilet room door related to dementia 3. Staff to provide verbal reminders/ directions to use toilet at scheduled times 9/15/14 Has remained dry during day shift on 12 of 14 days and dry during 4. Check q 2 hrs during night for toileting Evaluation evening shift 11 of 14 days on this toileting schedule. Is unable to needs/ incontinent care tell staff when he needs to toilet, and is unable to find toilet independently. He will use toilet when taken by staff and verbally cued. Continue with current scheduled toileting plan. Tom Tomato, RN 9/15/14 6/20/14 Turning/ At risk for additional skin Will remain free from 1. Turn/reposition q 2 hrs when in bed Repositioning breakdown related to unable additional skin breakdown 2. Reposition q 1 hr when in wheelchair to turn/reposition self in x 90 days 3. Alternating air mattress bed/chair 4. Gel cushion in wheelchair 5. Monitor skin for new breakdown q shift 9/15/14 Has been turned and repositioned per plan daily during this observation period. Alternating air mattress on bed and gel cushion in Evaluation chair as ordered. Remains free of additional skin breakdown with this schedule. Continue with current turning/repositioning schedule x 90 days. Tom Tomato, RN 9/15/14 Resident: Double Chocolate Almond Medical Record # 3003 Room #303 Example #3
8 Restorative Nursing Care Plan and Flow Record Month/Year: September 2014 ARD: 9/15/14 Directions: Use one form for each program. Complete and describe program, problem, measurable goals, and interventions. Be specific. Record direct restorative minutes daily in shift box. Be sure to initial when service is provided and sign form (full signature, title). A licensed nurse must evaluate the program within the quarter. Notes must be dated and signed. Program: Communication Problem: At risk for decline, requires group involvement/stimulation Goal: Maintain communication abilities Interventions: 1) Assist to group communication 6 days week; 2) May read and discuss newspaper articles; 3) Encourage to discuss past life or family; 4) Sing hymns Evaluation: 9/15/14, 2:00 pm. Enjoys talking about past life and singing hymns. 7-3 min X CA CA CA CA PP PP PP PP CA CA CA PP PP PP CA CA PP PP PP PP PP PP CA CA CA CA X 3-11 min X EE EE EE EE GA GA GA GA EE EE GA GA GA EE EE EE GA GA GA GA EE EE GA GA EE EE X Full Signature and Title Full Signature and Title PP Patty Peach, CNA CA Carmella Apple, CNA EE Edgar Eggplant, CNA GA Gus Asparagus, CNA Full signatures required to authenticate initials. Resident Name Medical Record Number Room Number Lemon Custard Example #4a This form is not endorsed by any state or government agency.
9 Restorative Nursing Care Plan and Flow Record Month/Year: September 2014 ARD: 9/15/14 Directions: Use one form for each program. Complete and describe program, problem, measurable goals, and interventions. Be specific. Record direct restorative minutes daily in shift box. Be sure to initial when service is provided and sign form (full signature, title). A licensed nurse must evaluate the program within the quarter. Notes must be dated and signed. Program: Communication Problem: New CVA with expressive aphasia, unable to consistently communicate wants and needs Goal: Will be able to use communication board to communicate wants and needs in 4 weeks Interventions: Keep communication board within reach; when asking a question, encourage to point to picture or words on board; show family how to use communication board; encourage family to use communication board; add pictures or words as needed; allow time for response Evaluation: 9/15/14, 2:00 pm. Since implementation of communication board 2 weeks ago, Mrs. Custard is able to let staff know if she is hungry, thirsty or in pain. Added TV and newspaper to board. Will continue program for 2 more weeks, then re-evaluate. Butter Pecan, RN 9/30/14, 10:00 am. Resident using communication board without difficulty. Program d/c d. Butter Pecan, RN 11-7 min. 7-3 min X X CA CA CA PP CA PP PP PP PP CA CA CA CA PP PP PP CA CA CA PP PP PP PP PP CA PP CA CA CA X X 3-11 min. Full Signature and Title Full Signature and Title PP Patty Peach, CNA CA Carmella Apple, CNA Full signatures required to authenticate initials. Resident Name Medical Record Number Room Number Lemon Custard Example #4b This form is not endorsed by any state or government agency.
10 Restorative Nursing Program Flow Sheet Day of the Month Dressing Help dress and undress daily EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE C A CA CA CA CA GA GA GA GA GA OO OO OO GA GA GA GA OO OO OO OO GA GA GA OO OO OO GA GA GA GA GA OO OO OO Eating Encourage to eat daily EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE C A CA CA CA CA GA GA GA GA GA OO OO OO GA GA GA GA OO OO OO OO GA GA GA OO OO OO GA GA GA GA GA OO OO OO Communication Talk to resident during care EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE C A CA CA CA CA GA GA GA GA GA OO OO OO GA GA GA GA OO OO OO OO GA GA GA OO OO OO GA GA GA GA GA OO OO OO Bed Mobility Assist to turn in bed PP PP PP PP PP BB BB BB BB BB PP PP BB BB BB BB BB PP PP BB BB BB PP PP PP PP PP BB BB BB Transfers Assist with all transfers EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE C A CA CA CA CA GA GA GA GA GA OO OO OO GA GA GA GA OO OO OO OO GA GA GA OO OO OO GA GA GA GA GA OO OO OO AROM EE GA PP EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE CA CA CA CA CA EE EE EE EE EE C A CA CA CA CA GA GA GA GA GA OO OO OO GA GA GA GA OO OO OO OO GA GA GA OO OO OO GA GA GA GA GA OO OO OO Full Signature and Title Full Signature and Title Edgar Eggplant, CNA CA Carmella Apple, CNA Gus Asparagus, CNA OO Ollie Orange, CNA Patty Peach, CNA BB Brock Broccoli, LPN Problem: Needs assist with ADLs. Goal: Will participate with ADLs as able. Evaluation: Continue to assist with ADLs daily as needed. Encourage to do as much for self as possible. 9/15/14 Butter Pecan RN Resident: Bubble Gum Example #5 Month Sept Year 2014 Prepared by Myers and Stauffer LC 2014
11 Treatment Administration Record BB NB TS Day of the Month 11-7 PROM minutes daily Apply right hand splint daily On at 8 am Off at 8 pm Betty Bones, LPN Nettie Bones, RN Ted Skeleton, CNA Full Signature and Title 7-3 TS TS TS TS TS ES ES ES ES ES TS TS TS TS TS ES ES ES ES ES TS TS TS TS ES ES ES TS TS TS TS NB NB NB NB NB LB LB NB NB NB NB NB LB LB LB LB LB NB NB NB LB LB LB LB NB NB NB NB LB LB LB BB BB BB BB NS NS NS NS NS BB BB BB BB NS NS NS NS BB BB BB NS NS NS BB BB BB BB BB NS NS NS LB NS ED Lettie Bones, LPN Ned Skeleton, RN Ed Skeleton, CNA Full Signature and Title Resident Name: Raspberry Sherbet Example #6 Prepared by Myers and Stauffer LC Month Sept Year
12 Restorative Nursing Care Plans Date Problem/Program Goal Interventions 9/15/14 #1 Unable to move right Will remain free of 1. PROM exercises per policy /procedures side related to CVA/ contractures x 90 days 15 mins/daily PROM Program (other than right hand) 2. Stop if complains of pain 3. Refer to OT/PT for pain or decrease in ROM Evaluation: Remains unable to move right side related to CVA. PROM provided 15 minutes per day, 5 reps per joint. No pain reported with exercises. No contractures other than right hand. Able to move left side independently. Butter Pecan, RN 9/15/14 contracture, decrease ROM 9/15/14 #2 Contractures right Will wear right hand 1. Right hand splint on q am, off hs hand related to CVA/ splint daily x 90 days 2. Assess for red or open areas on hand Splint program 3. PROM to hand before placing splint on and when removing 4. Refer to OT/PT as indicated for increase in Evaluation: Right hand splint is applied every morning at 8 AM and removed every evening at 8 PM. No red or open areas on hand, no pain reported with wearing of splint. Hand remains contracted. Continue current program. Butter Pecan, RN 9/15/14 Resident: Raspberry Sherbet Medical Record # 6006 Room # 606 Example #6
13 Restorative Nursing Care Plan and Flow Record Month/Year: September 2014 ARD: 9/15/14 Directions: Use one form for each program. Complete and describe program, problem, measurable goals, and interventions. Be specific. Record direct restorative minutes daily in shift box. Be sure to initial when service is provided and sign form (full signature, title). A licensed nurse must evaluate the program within the quarter. Notes must be dated and signed. Program: AAROM right hand and fingers Problem: Contractures of right hand and fingers due to CVA, unable to completely open hand and straighten fingers independently Goal: Will be able to open right hand and straighten fingers with assist daily through next review/90 days Interventions: AAROM to right hand and fingers, 8-10 reps each joint before and after splint application; move joints gently; stop if complains of pain; refer to OT if decrease in range of motion Evaluation: 9/15/14, 2:00 pm. Right hand and fingers still contracted but able to move right hand and fingers through AAROM exercises with assistance. No pain with movement and no increase in resistance to movements. AAROM exercises not done 2 days during this observation period, as splint was off due to open area on palm. Continue with AAROM program when splint resumes. Olive Oliver, RN 6 am Minutes/ X AAROM EE EE CA EE EE CA CA CA CA EE EE EE EE CA CA CA CA EE EE EE EE CA CA CA CA EE EE EE CA CA X 4 pm Minutes/ X AAROM GA GA GA OO OO OO GA GA PP PP PP PP PP GA GA OO OO OO OO GA GA GA GA OO OO PP PP PP GA GA X Full signatures required to authenticate initials. Full Signature and Title Full Signature and Title Full Signature and Title EE Edgar Eggplant, LPN CA Carmella Apple, LPN PP Patty Peach, RN GA Gus Asparagus, LPN OO Ollie Orange, RN Resident Name Medical Record Number Room Number Cherry Cordial Example #7 This form is not endorsed by any state or government agency.
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