Plans Comprehensive Care Planning for Long Term Care Facilities: A Guide to Resident Assessment Protocols (RAPs) and Interdisciplinary Care Plans. Volume 1 By Holly F. Sox, R, RAC-C Published by Robin Technologies, Inc. Creators of Careplans.com
Introduction and Acknowledgements This book is intended as a starting point for practitioners in the long-term care setting. The care plans are templates, with space for individualizing based on resident-specific needs. It is my goal that the care plans and RAP templates will be useful to beginners and experienced Resident Assessment Coordinators, as well as other interdisciplinary team members, such as dietitians, social workers and activities professionals. There are many people and institutions who need to be mentioned and thanked. First, I want to thank Gary Jorgenson, for giving me the opportunity to work with Robin Technologies, and to develop this project. It's the greatest job anyone could have. Thanks to Beth Birch, Dennis Caldwell, Marilynn Comar, Keith Paul, Tom Porter, Cheryl Terry and Mel Stepp, for providing leadership and serving as examples to me in administration. Thank you to AAAC for providing a foundation of knowledge and training, and a network for ACs across the country, to share our knowledge and support for each other. Thank you to the members of CMDG, the Case Mix Discussion Group for stimulating my interest and desire for more knowledge. My biggest thanks go to my family. To my mom and dad, thanks for paving the way into this profession of nursing, and for being such wonderful examples of the kind of nurse that I always want to be. And, to Mike, Cody and Mikey, thank you for letting me sit at my computer till late at night, writing one more care plan. About the Author Holly Sox, R, RAC-C Holly Sox graduated Magna cum laude with a B.S. in ursing from the University of South Carolina in 1988. After graduating, she has worked as an MDS Coordinator, Clinical urse, Special Procedures urse, Office urse, as well as a Staff urse. In 2003, she was awarded AC of the Year by the American Association of urse Assessment Coordinators (AAAC). Currently, Holly serves as the Resident Assessment Director at J F Hawkins ursing Home in ewberry, South Carolina and as Clinical Editor for Careplans.com.
TABLE OF COTETS 1 4 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 40 42 44 46 49 50 51 52 53 54 55 56 57 59 61 63 64 65 66 67 68 69 70 71 73 74 75 77 79 Introduction to the RAPs RAP Templates 1. Activities 2. ADL/Functional Rehabilitation Potential with ADL Supplement 3. Behavioral Symptom 4. Cognitive Loss 5. Communication 6. Dehydration 7. Delirium 8. Dental Care 9. Falls 10. Feeding Tubes 11. Mood State 12. utritional Status 13. (Optional) Pain 14. Physical Restraints 15. Pressure Ulcers 16. Psychosocial Well-Being 17. Psychotropic Drug Use 18. Urinary Incontinence/Indwelling Catheters 19. Visual Function 20. Sample Completed RAP Introduction to Care Planning RAP Care Plan Templates 1. Activities- Dependent on Staff for Activities 2. Activities- Little or o Activity Involvement 3. ADL- Self-Care Deficit 4. ADL- Limited Mobility 5. Behavior Problem 6. Behavior Problem- Refusing Feeding 7. Behavior Problem- Wandering 8. Cognitive Loss 9. Communication- Impaired Expressive or Receptive Communication 10. Communication- Aphasia 11. Dehydration/Fluid Balance- Potential or Actual Dehydration 12. Dehydration/Fluid Balance- Fluid Overload 13. Delirium or Acute Confusional Episode 14. Dental Care 15. Falls 16. Feeding Tubes 17. Mood Problem 18. Mood State- Depression 19. utrition- Potential or Actual utritional Problem 20. utrition- Obesity 21. Pain 22. Physical Restraints 23. Pressure Ulcer- Potential or Actual 24. Psychosocial Well-Being- Potential for Adjustment Reaction
80 81 82 83 84 85 86 87 88 89 91 92 93 94 95 96 97 99 100 102 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 122 123 124 125 126 127 129 130 131 133 25. Psychosocial Well-Being Problem 26. Psychotropic Drug Use 27. Urinary Incontinence 28. Indwelling Catheter 29. Vision Problem Care Plans for Disorders of the Cardiovascular System 1. Potential for Altered Cardiac Output 2. Angina 3. Congestive Heart Failure 4. Coronary Artery Disease 5. Deep Vein Thrombosis 6. Dysrhythmia 7. Hypertension 8. Hypotension 9. Pacemaker 10. Peripheral Vascular Disease 11. Ineffective Tissue Perfusion Care Plans for Disorders of the Endocrine System 1. Diabetes Mellitus 2. Diabetic Ketoacidosis (DKA) 3. HHK (Hyperglycemic Hyperosmolar on Ketotic Syndrome) 4. Hyperparathyroidism 5. Hyperthyroidism 6. Hypothyroidism Care Plans for Disorders of the Gastrointestinal System 1. Colostomy 2. Constipation 3. Diarrhea 4. Diverticulosis 5. Gastroesophageal Reflux Disease (GERD) 6. GI Bleeding 7. Hemorrhoid 8. Hepatitis Care Plans for Disorders of the Genitourinary System 1. Benign Prostate Hypertrophy 2. Chronic Renal Failure 3. Urinary Retention 4. Urinary Tract Infection Care Plans for Disorders of the Integumentary System/Connective Tissue 1. Eczema 2. Foot Problems 3. Lupus 4. Psoriasis 5. Scabies 6. Scleroderma 7. Surgical Wound
134 135 136 138 139 141 143 144 145 146 148 150 151 152 153 154 156 157 159 160 161 162 163 164 165 166 167 168 170 172 174 176 177 178 180 181 182 183 185 Care Plans for Disorders of the Musculoskeletal System 1. Amputation 2. Arthritis (DJD/Osteoarthritis/Gout/Rheumatoid) 3. Fracture 4. Hip Fracture 5. Osteoarthritis 6. Osteoporosis Care Plans for Disorders of the eurological System 1. Cerebrovascular Accident 2. Huntington s Disease 3. Multiple Sclerosis 4. Parkinsons Disease 5. Seizure Disorder Care Plans for Disorders of the Respiratory System 1. Chronic Obstructive Pulmonary Disease/Asthma 2. Ineffective Airway Clearance 3. Tracheostomy 4. Tuberculosis Care Plans for Disorders of the Sensory Organs 1. Eye discomfort 2. Hearing Loss Care Plans for Hematologic/Oncologic Disorders 1. Anemia 2. Cancer 3. Thrombocytopenia Care Plans for Medication or Treatment Effects 1. Anticoagulant 2. Chemotherapy 3. Dialysis 4. Intravenous Therapy 5. Radiation Care Plans for Psychosocial Issues 1. Death and Dying Issues 2. Potential Abuse 3. Sexual Dysfunction 4. Short-Term Stay Care Plans for Safety and Security Issues 1. Potential for Elopement 2. Smoking
PLA OF CARE Problem(s) Goal(s) Approach(es) Dept Review Behavior problem: wandering related to Alzheimers disease Other dementia CVA Delirium ew environment ew routine Mood problem Relationship problem Will wander safely within environment aeb no falls, elopement events, injury through review date. OR Will have more purposeful behavior with wandering less than Daily/weekly/monthly by review date. Monitor behavior and attempt to determine pattern, frequency, intensity. Review for recent changes such as bed move, room change, medication changes, change in cognitive function, new staff members, change in treatment program, loss of family member. Attempt to determine cause of wandering and relieve, if possible. (ie, boredom, looking for someone or something) Anticipate and meet needs. Respond promptly to all requests for assistance. Keep familiar routines intact if possible. Maintain familiar items in environment, with well-lit room. Praise any purposeful movements, non-wandering behavior. Walk with resident daily or more frequently, with purpose. Provide a program of activities to minimize potential for wandering while meeting need for social/cognitive stimulation. Mark room door with name or familiar photo, to aid in remembering room location.,sw,act SAMPLE ACT ACT Use security alarm bracelet or other sensor system as needed to reduce risk of elopement from facility. Ensure that hallways are free from spills, clutter and other hazards. HSK Resident ame ID# Room # Physician 2004 careplans.com Robin Technologies Inc. 670 Lakeview Plaza Blvd., Suite J. Worthington OH 43085 614-888.3001 www.robintek.com