Name:
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Problem / Need / Strength
Behavior problem related to Dx. SDAT as evidenced by: Combative behavior toward family
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Goal(s)
Will have fewer episodes of _________ behavior daily/weekly by review date.
Will have no evidence of behavior problems by review date.
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Intervention(s)
Administer medications as ordered and monitor for side effects, effectiveness.
Anticipate and meet needs.
Assist in developing more appropriate methods of coping and interacting.
Encourage to express feelings appropriately, let staff know when s/he is getting upset.
Explain all procedures before starting and allow resident time to adjust to changes. If reasonable, discuss behavior with resident.
Explain/reinforce why behavior is inappropriate and/or unacceptable.
Intervene as needed to protect the rights and safety of others.
Approach/speak in calm manner.
Divert attention.
Remove from situation and take to another location as needed.
Monitor behavior episodes and attempt to determine underlying cause.
Consider location, time of day, persons involved, situations.
Document behavior and potential causes
Offer incentives for appropriate behavior, as indicated.
Praise any indications of progress/improvement in behavior.
Provide a program of activities that is of interest and accommodates resident’s status.
Minimize potential for disruptive behavior by offering tasks which divert attention, engage in structured activities.
Psychiatry Evaluation prn
Staff to provide opportunities for positive interaction, attention.
Stop and talk with him/her as passing by.
Blindness due to [ SPECIFY ]
Name:
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Problem / Need / Strength
Blindness due to [ SPECIFY ]
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Goal(s)
Will be able to move about in own room, taking care of feeding, dressing and toileting needs by ____.
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Intervention(s)
Arrange food on tray so patient/resident can feed self unassisted.
Arrange for books on tape, large print reading material as desired.
Describe entire room to assist patient/resident to form mental image.
Furniture in room shall be placed as directed by patient/resident and will remain constant.
Keep bed in low position with wheels locked.
Set up equipment for ADL care and describe location of objects.
Provide assistance with daily care as needed. Set up plate, tray in clock positions explaining the position of foods.
Body image disturbance (actual or potential) due to colostomy/urinary ileostomy.
Name:
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Problem / Need / Strength
Body image disturbance (actual or potential) due to colostomy/urinary ileostomy.
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Goal(s)
Will adjust to new body image/presence of ostomy as evidenced by expressing acceptance, exhibiting no s/sx of discomfort or distress related to ostomy by review date.
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Intervention(s)
Allow to vent feelings and frustrations regarding ostomy
Arrange for attendance at ostomy support group if possible and resident desires.
Refer to appropriate community resources as indicated.
Do not make negative remarks related to odor or show disgust when doing colostomy changes or stoma care.
Ensure that ostomy appliance is covered and provide deodorizers as needed to maintain dignity. Provide necessary supplies and equipment for self care if desired.
Teach/instruct ostomy care techniques and allow to participate at own pace.
Do not rush. Be patient.
Bowel incontinence related to [ SPECIFY ]
Name:
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Problem / Need / Strength
Bowel incontinence related to [ SPECIFY ]
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Goal(s)
Episodes of incontinence will be managed by nursing staff as evidenced by decrease in episodes x 90 days.
Will be free from skin breakdown and good skin integrity will be maintained x 90 days.
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Intervention(s)
Assist patient/resident by toileting routinely [frequency].
Assist, remind to void at specified intervals according to bladder training schedule posted. Assist/teach to reposition self to eliminate pressure (shifting own weight or turning).
Body/skin audit at least weekly.
Comprehensive evaluation of incontinence pattern to determine potential for management program. D
ocument # of times incontinent per shift.
Evaluate for bowel management program.
Implement bowel re-training program with all personnel, patient/resident and family.
Instruct in kegel exercises to strengthen sphincter control.
Keep patient/resident dry and check skin for any red areas.
Monitor bowel movements Q/shift. Report if no BM Q2-3 days.
Monitor skin daily for signs of pressure areas.
Peri-care with each incontinence episode.
Place on bowel management program to include [ ].
Report areas of skin redness or breakdown.
Reposition at least q 2 hours and prn. Skin care to include [ Specify ].
Teach patient/resident and family to help in observing skin changes and relieving pressure.
Use positioning and pressure relieving devices (eggcrate/air flow mattress/pillows).
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