Care Plans - Online Example
This shows the information that can be accessed online. The resident’s name has been changed to preserve privacy and the reports, unlike our actual resident reports, are not updated. Please click on each "activity of daily living" to see more information.
Care Plan for Mrs Jane Smith
Evaluated on 10th July 2008
Current Situation
Jane suffered a fall and broke her hip prior to coming into the home. She has lost confidence and is worried about falling again.She is fully recovered from her hip joint repair and is fully mobilised.She uses one walking stick.On some days she finds it difficulty to initiate walking which she finds very frustrating.
Objective
To maintain Jane’s mobility. To avoid trip hazards.
Action
Ensure that there are no trip hazards in Jane’s bedroom. Offer to accompany Jane on days when her walking is difficult.
Evaluated on 10th July 2008
Current Situation
Jane has Parkinson's Disease which makes it difficult for her to swallow tablets. Most of her medication is therefore given in syrup or soluble form. On days when she is agitated she may refuse her medication. In these instances it is best to withdraw and try again..
Objective
For Jane to receive the maximum therapeutic effect from her prescribed medication..
Action
RGN to administer all of Jane's prescribed medication.If refused, withdraw and try again later. Monitor for therapeutic or side effects and report to GP.
Evaluated on 10th July 2008
Current Situation
Jane has no problems in this area. She is able to make her needs known and is able to request changes in her physical environment.
Objective
To maintain a stable body temperature and to ensure that Jane is comfortable at all times.
Action
Provide Jane with a warm and well ventilated environment. Ask Jane if she is comfortable and encourage her to request any changes she may require.
Evaluated on 10th July 2008
Current Situation
Jane suffers from mild asthma and has a history of recurrent chest infections with bouts of bronchitis in the winter months for which she requires antibiotics. At present her chest is clear.
Objective
To maintain good respiratory health.
Action
Ensure that Jane’s bedroom is warm and well aired avoiding draughts. Be observant of Jane if she develops a persistent cough when she will need to see the doctor. Be aware that Jane can show signs of confusion when she has a chest infection
Evaluated on 10th July 2008
Current Situation
Jane has Parkinson’s Disease and is fully able to communicate her needs. She has asked that all staff call her Jane. She wears spectacles for reading and wears a hearing aid in her right ear. On the days when she experiences problems with her mobility she can be anxious and agitated.
Objective
To maintain effective communication.
Action
Ensure that Jane’s hearing aid is operating efficiently. If she is experiencing anxiety take time to chat to her and give reassurance.
Evaluated on 10th July 2008
Current Situation
Jane is a Christian and enjoys services and hymn singing. She has expressed a wish to be cremated. She has a caring family who will make all arrangements for care at the end of life.
Objective
To carry out Jane’s wishes.
Action
Inform Jane’s family of all changes in her health. Consult them for further information regarding wishes for any treatment that may be offered.
Evaluated on 10th July 2008
Current Situation
Jane is fully continent. She has a history of diverticulitis and is prescribed movicol to maintain regularity.
Objective
To prevent a flare up of diverticulitis.
Action
Monitor frequency of bowel action and inform RGN or GP if this becomes abnormal.
RGN to administer movicol.
Evaluated on 10th July 2008
Current Situation
Jane requires assistance with some aspects of hygiene from one carer. She likes to shower every other morning. Jane has very dry skin which requires application of emollients once a day. She wears dentures.
Objective
To maintain high standard of hygiene
Action
Provide one carer to assist Jane with hygiene. Offer her a shower or a wash daily in her ensuite. Assist with application of emollient to her back and legs after her wash. Offer to manicure finger nails as necessary. Offer to make appointments for hairdressing and chiropody as necessary.
Evaluated on 10th July 2008
Current Situation
Jane suffers with Parkinson’s Disease. Her cognitive abilities are unaffected but on days when she experiences difficulty with mobility she may become anxious and agitated. She enjoys company and looks forward to visits from her family.
Objective
To maintain stable level of mental well being.
Action
Spend time chatting to Jane and encourage her to mix with other residents. Offer reassurance if she is agitated.
Evaluated on 10th July 2008
Current Situation
Jane has Parkinson’s Disease and has difficulty with swallowing. Jane likes most food and fruit but prefers to avoid hot or spicy dishes. She most enjoys a cup of tea and a slice of sponge cake.
Objective
To ensure that Jane receives optimum nutrition to maintain stable weight.
Action
Ensure Jane receives a soft diet. Encourage a high fruit and fluid intake to avoid constipation. Be aware of choking hazard. Weigh monthly.
Evaluated on 10th July 2008
Current Situation
Jane’s skin is intact and she has no pressure sores. Her skin is very dry and requires application of emollient.
Objective
To maintain skin integrity and to prevent pressure sores occurring
Action
Inspect skin daily and report any signs of redness to RGN. Apply emollient to back and legs daily.
Evaluated on 10th July 2008
Current Situation
Jane is able to maintain her own safety.
Objective
To maintain a safe environment for Jane.
Action
Ensure there are no trip hazards such as loose carpet or wet floor.
Evaluated on 10th July 2008
Current Situation
Jane usually sleeps well. She is not prescribed sedation. She likes to retire at 9pm after a warm drink. She regularly wakes at 3am but is able to go back to sleep until 7am
Objective
To enable Jane to sleep well
Action
Offer Jane a warm drink before she retires. Check two hourly during the night. Encourage Jane to call when she wakes in the middle of the night and offer a chat and a drink.
Evaluated on 10th July 2008
Current Situation
Jane is a solicitor’s wife and has spent all her life living in Guildford. She was a primary school teacher. She is a widow and has three children, a son and two daughters. They all visit Jane regularly and are very caring. Jane is a Christian and enjoys services especially the hymn singing.; She enjoys the company of other people and joins in activities in the lounge during the day. She enjoys board games, especially Scrabble and is good at completing crosswords. She likes to go to her room after tea to watch television.
Objective
To ensure Jane’s social needs are met and that she enjoys her life here in the home.
Action
Ensure Jane has received her newspaper “The Daily Telegraph” every day. Keep Jane informed as to the entertainment and activities on offer for the day. Facilitate visitors at any time. Offer to play a board game with her. Talk to Jane about her family.