Name:
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Problem / Need / Strength
Chronic constipation related to [ SPECIFY ]
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Goal(s)
Will have no fecal impaction x 90 days.
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Intervention(s)
Assist patient/resident by toileting routinely [frequency].
DOC elimination pattern.
Evaluate knowledge of fluids and fiber in prevention of constipation.
Monitor for signs/symptoms of GI distress.
Monitor meals and encourage to eat foods high in bulk and fiber.
Natural laxative as ordered.
Stool softeners as ordered to avoid straining or constipation.
Chronic diarrhea related to [ SPECIFY ]
Name:
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Problem / Need / Strength
Chronic diarrhea related to [ SPECIFY ]
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Goal(s)
Will be free from signs and symptoms of diarrhea x 90 days.
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Intervention(s)
Administer antidiarrheal medications, bulking agents as ordered and monitor for side effects, effectiveness.
Communicate any special dietary needs to dietician.
Determine and avoid food intolerences.
Document number of episodes of diarrhea.
Observe for and report any nausea, vomiting, diarrhea, abdominal distension, cramping, allergic reactions, glucosuria, polyuria or signs of fluid and electrolyte imbalance.
Cognitive loss/dementia related to Alzheimers dementia, aeb: impaired decision making, short and/or long term memory loss, neurological symptoms.
Name:
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Problem / Need / Strength
Cognitive loss/dementia related to Alzheimers dementia, aeb: impaired decision making, short and/or long term memory loss, neurological symptoms.
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Goal(s)
Will maintain or improve current level of cognitive function by/through review date as evidenced by: [specify]
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Intervention(s)
Administer medications as ordered and monitor for side effects
Communicate with staff, family, MD regarding resident’s capacity, needs.
Discuss concerns about confusion, disease process, NH placement with family prn
Observe, document, report to MD prn:
Dementia s/sx:
· Decision making problem
· Memory problem
· 2 or more recall or general awareness problems
· Difficulty expressing self or understanding others
Neurological status
Changes in status
Promote dignity. Converse with resident and ensure privacy while providing care.
Provide a homelike, therapeutic environment:
· Clocks/calendars visible
· Adequate, glare-free light
· Consistent routine
· Safety checks
· Appropriate sensory stimulation. Avoid constant noise level if possible.
· Limit sensory input when resident agitated
· Use task segmentation prn
· When possible, use familiar objects from home, or objects with sentimental value, family pictures, etc.
Provide a program of activities that accommodates resident’s problem. Engage in structured activities, sensory stimulation activities
Provide cues, prompting, demonstration if resident is unable to complete a task independently
Provide reality orientation and validation prn.
Use communication techniques which facilitate optimal interaction:
· Use preferred name
· Identify yourself with each contact as needed
· Face when speaking and make eye contact
· Turn off TV, radio, etc
· Request feedback to ensure understanding
· Use brief, simple, consistent words, cues and statements
· If resident is restless or agitated, shorten conversation. Resume later prn
Communication problems related to hearing deficit.
Name:
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Problem / Need / Strength
Communication problems related to hearing deficit.
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Goal(s)
Will effectively communicate simple needs to staff such as [toileting/food or drink, etc.] x 90 days.
Will utilize an alternative method of communication ( ) x 90 days.
Will wear hearing aid[s] x 90 days.
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Intervention(s)
Insert hearing aide in [ ] ear before breakfast. Clean surface before inserting.
Instruct in location & use of amplified telephone.
Keep hearing aide batteries in refrigerator, labelled with paitent's/resident's name.
Seat at front of [activity/function/speaker] and attempt to involve in program.
Use communication techniques which facilitate optimal interaction: Speak clearly and distinctly, but do not over-enunciate. Do not yell. Ask for feedback to ensure understanding. Repeat as needed. Use brief, simple, consistent words, cues and statements.
Uses amplifying device: [ SPECIFY ]. . Make available for use.
Verify that hearing aid is in place before transporting to activities.
Complains about food and leaves [ ]% of food uneaten.
Name:
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Problem / Need / Strength
Complains about food and leaves [ ]% of food uneaten.
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Goal(s)
Will eat at least [ ]% of [ ] meal per day x 90 days.
Will maintain stable weight +/- 5 lbs. x 90 days.
Will not lose weight from current weight of [ ] lbs. x 90 days.
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Intervention(s)
Avoid following foods: [ SPECIFY ].
Calculate [ ] calories, protein & fluid needs. Provide supplement as needed: [ SPECIFY ].
Diet as ordered per physician.
Monitor weight gain/loss for [month]. Report to physician.
Notify physician of any significant weight change.
Offer small feedings [ ] times per day.
Offer substitutes for uneaten foods.
Position upright for meals.
Refer to Dietitian to offer foods that patient/resident likes within limits of therapeutic diet.
Stay with during meals.
Weigh [ ] & report.
When serving tray, assist as needed with opening packets, pouring liquids, cutting foods, etc. Before removing tray, ask if s/he has had enough to eat. Offer substitute/supplement if consumes less than 50%.
Complains of frequent hunger.
Name:
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Problem / Need / Strength
Complains of frequent hunger.
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Goal(s)
Will not complain of hunger by ____.
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Intervention(s)
Dietary to do food intake study for ____ days.
Dietitian will visit to provide counseling for patient/resident on ____ basis.
Increase portions of ____ nutrients to provide for ____.
Monitor weight per facility protocol or as ordered, and record in chart. Notify RD and health care provider of significant wt changes.
Provide between meal snacks consisting of ____ at ____.
Complains of mouth pain.
Name:
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Problem / Need / Strength
Complains of mouth pain.
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Goal(s)
Will be able to drink and eat without having pain by ____.
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Intervention(s)
Administer medications, mouthwashes as ordered and monitor for side effects, effectiveness.
Assist patient/resident with oral care as needed.
Schedule dental evaluation on ____ basis for the patient/resident.
See dentist yearly and prn.
Verbally remind patient/resident when oral hygiene should be performed.
Confined to a chair with safety belt or positioning pillow that prevents rising related to [ SPECIFY ]
Name:
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Problem / Need / Strength
Confined to a chair with safety belt or positioning pillow that prevents rising related to [ SPECIFY ]
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Goal(s)
Will maintain current mobility status x 90 days.
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Intervention(s)
Assess/record/report to MD prn s/sx of decline in function, isolation, withdrawal related to restraint use.
Discuss with resident/family any concerns, fears, issues related to restraint use.
Inspect skin around and under restraint for s/sx of breakdown or pressure areas. Notify MD if present and provide treatment per protocol.
Release restraint during supervised activities, direct care, meals.
Review record and ensure valid consent on chart if applicable.
Conflict between patient/resident and family is present.
Name:
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Problem / Need / Strength
Conflict between patient/resident and family is present.
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Goal(s)
Will express feelings about family situation appropriately within review period.
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Intervention(s)
Encourage patient/resident to talk about feelings of anger and provide ____.
Invite family to talk with patient/resident about ____.
One-to-one visits on a daily basis from social services.
Show patient/resident that he/she is accepted.
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