Focus:

RISK FOR IMPAIRED CARDIAC OUTPUT R/T:

Goal:

MAINTAIN BP WITHIN INDIVIDUALLY ACCEPTABLE RANGE AND DEMONSTRATE STABLE CARDIAC RHYTHM AND RATE.

Interventions:

• NOTE PRESENCE AND QUALITY OF CENTRAL AND PERIPHERAL PULSES
• AUSCULTATE HEART AND BREATH SOUNDS
• OBSERVE SKIN COLOR, MOISTURE, TEMPERATURE, AND CAPILLARY REFILL TIME
• REPORT ANY DEPENDENT OR GENERALIZED EDEMA
• WEIGHTS PER PHYSICIAN'S ORDERS

Focus:

RISK FOR IMPAIRED GAS EXCHANGE R/T

Goal:

PATIENT WILL BE FREE FROM ANY SYMPTOMS OF RESPIRATORY DISTRESS

Interventions:

• ASSESS RESPIRATORY RATE AND DEPTH. NOTE THE USE OF ACCESSORY MUSCLES OR SHORTNESS OF BREATH
• ELEVATE HEAD OF BED AND ASSIST PATIENT TO ASSUME POSITION TO EASE WORK OF BREATHING.
• ENCOURAGE DEEP, SLOW, OR PURSED-LIP BREATHING AS INDIVIDUALLY NEEDED AND TOLERATED
• ASSESS AND ROUTINELY MONITOR SKIN AND MUCOUS MEMBRANE COLOR
• AUSCULTATE BREATH SOUNDS, NOTING AREAS OF ADVENTITIOUS SOUNDS
• DIAGNOSTICS PER PHYSICIAN'S ORDERS

Focus:

IMPAIRED PHYSICAL MOBILITY R/T

Goal:

PATIENT WILL MAINTAIN FUNCTIONAL MOBILITY AS LONG AS POSSIBLE WITHIN LIMITATIONS OF DISEASE PROCESS

Interventions:

• ASSESS THE PATIENT'S FUNCTIONAL ABILITY FOR MOBILITY/ADL PERFORMANCE AND REPORT ANY CHANGES
• PROVIDE RANGE OF MOTION EXERCISES EVERY SHIFT
• PATIENT TO PARTICIPATE IN ADLS AS TOLERATED
• THERAPY TO EVALUATE AS NEEDED

Focus:

RISK FOR ABNORMAL LABS/DIAGNOSTICS R/T

Goal:

LAB VALUES WILL BE WITHIN ACCEPTABLE RANGE THOUGH NEXT REVIEW DATE

Interventions:

• MEDICATIONS PER PHYSICIAN'S ORDERS
• LABS/DIAGNOSTICS AS NEEDED
• REPORT TO PHYSICIAN ANY SIGN OF ALTERED MENTAL STATUS OR ABNORMAL ELECTROLYTES

Focus:

RISK FOR FURTHER COGNITIVE DECLINE R/T

Goal:

RESIDENT WILL BE FREE FROM FURTHER DECLINE THROUGH THE REVIEW DATE

Interventions:

• SPEECH THERAPY TO EVAL AND TX PER PO
• REORIENT PATIENT IN TIMES OF DISTRESS
• MEDICATIONS PER PO
• HELP RESIDENT ESTABLISH A ROUTINE UPON ADMISSION AND ADD IT TO THE CARE PLAN
• SOCIAL/ACTIVITIES TO VISIT PRN

Focus:

RISK OF FALLING R/T

Goal:

PATIENT WILL NOT EXPERIENCE A FALL DURING STAY AND WILL TRANSFER SAFELY TO THEIR ABILITIES

Interventions:

• ASSESS HISTORY OF FALLS
• REPORT ANY CHANGES IN MENTAL STATUS
• TRANSFER RESIDENT ACCORDING TO INDIVIDUAL PERFORMANCE IN ADL'S
• REVIEW PATIENT'S MEDICATIONS FOR ANY MEDICATIONS THAT WILL CAUSE DIZZINESS OR DECREASE BLOOD PRESSURE
• ENSURE ENVIORNMENT IS FREE OF FALLING HAZARDS (CORDS, SPILLS, ETC)

Focus:

IMPAIRED ABILITY TO SEE R/T

Goal:

RESIDENT WILL BE FREE FROM VISUAL DECLINE DURING THROUGH NEXT REVIEW DATE.

Interventions:

• ENCOURAGE RESIDENT TO OPEN BLINDS
• ENSURE ADEQUATE LIGHTING
• KEEP ITEMS IN REGULAR PLACES
• NOTIFY RESIDENT IF ITEMS NEED TO BE MOVED
• ASSIST WITH GLASSESS PRN (if applicable)

Focus:

RISK FOR IMPAIRED SKIN INTEGRITY R/T

Goal:

PATIENT WILL EXPERIENCE NO SKIN BREAKDOWN THROUGH THE REVIEW DATE

Interventions:

• OBTAIN BRADEN SCALE SCORE FOR THIS PATIENT
• ENSURE PATIENT MAINTAINS AN ADEQUATE DIET, EATING OVER 50% PER MEAL
• ASSESS PATIENTS ABILITY TO MOVE SELF IN BED
• ENSURE PAITENT TURNS AND IS REPOSITIONED EVERY TWO HOURS WHILE IN BED
• REPORT ANY NEW FINDINGS OF SKIN BREAKDOWN

Focus:

RISK FOR GI DISCOMFORT R/T

Goal:

RESIDENT DISCOMFORT WILL BE MINIMIZED DURING STAY

Interventions:

• MEDICATIONS PER PO
• ENCOURAGE RESIDENT TO REMAIN UPRIGHT FOR 30 MINS AFTER MEALS
• ENCOURAGE RESIDENT TO AVOID SPICY FOODS AND CAFFEINATED DRINKS
• ENCOURAGE WATER INTAKE

Focus:

PATIENT CODE STATUS:

Goal:

PATIENT AND FAMILY MEMBERS' WISHES WILL BE RESPECTED

Interventions:

• FLAG PATIENT'S CHART WITH CODE STATUS
• PATIENT'S CODE STATUS WILL BE FOLLOWED IN THE EVENT OF AN EMERGENCY
• IF TRANSFERRED TO HOSPITAL, ENSURE CODE STATUS IS SENT WITH PATIENT

Focus:

PATIENT WITH:

Goal:

PATIENT WILL MAINTAIN A STABLE MOOD STATE DURING STAY.

Interventions:

• MEDICATIONS PER PO
• ENCOURAGE RESIDENT TO OPEN BLINDS
• MONITOR FOR INCREASED RISK OF FALLS
• PSYCH CONSULT PRN
• SOCIAL AND ACTIVITIES TO VISIT PRN
• STAFF TO ATTEMPT TO KEEP HS ROUTINE FOR CONSISTENCY, SLEEP PATTERN DEVELOPMENT
• REPORT ANY SIGNS OR EXPRESSION OF SELF HARM AND PLACE PATIENT UNDER 1 ON 1 WATCH IF IT OCCURS

Focus:

RISK FOR IMPAIRED NUTRITION R/T

Goal:

RESIDENT WILL MAINTAIN ADEQUATE DIET/MAINTAIN WEIGHT THROUGH REVIEW PERIOD

Interventions:

• WEIGHTS PER PO
• DIET PER PO
• DIETARY TO UPDATE PREFERENCES
• SPEECH THERAPY TO EVAL AND TX PER PO
• MONITOR AND RECORD MEAL PERCENTAGES

Focus:

PATIENT TAKES ANTI-DEPRESSANT MEDICATIONS:

Goal:

PATINET WILL EXPERIENCE NO ADVERSE EFFECTS DUE TO MEDICATIONS AND NOT REPORT ANY INCREASED EPISODES OF DEPRESSION

Interventions:

• TAKE MEDICATIONS PER PHYSICIANS ORDERS
• REPORT ANY ADVERSE EFFECTS (INCREASED DEPRESSION, AGITIATION, DIZZINESS, ETC)
• DIETARY TO UPDATE PREFERENCES
• SPEECH THERAPY TO EVAL AND TX PER PO
• MONITOR AND RECORD MEAL PERCENTAGES

Focus:

PATIENT TAKES ANTI-ANXIETY MEDICATIONS:

Goal:

PATIENT WILL EXPERIENCE NO ADVERSE EFFECTS DUE TO MEDICATIONS AND BE ABSENT OF INCREASING ANXIETY

Interventions:

• TAKE MEDICATIONS PER PHYSICIANS ORDERS
• REPORT ANY ADVERSE EFFECTS (DROWSINESS, SEDATION, CONFUSION, ETC)
• DIETARY TO UPDATE PREFERENCES
• SPEECH THERAPY TO EVAL AND TX PER PO
• MONITOR AND RECORD MEAL PERCENTAGES

Focus:

PATIENT TAKES DIURETIC MEDICATIONS:

Goal:

PATIENT WILL EXPERIENCE NO ADVERSE EFFECTS DUE TO MEDICATIONS, AND BE ABSENT OF WORSENING SIGNS OF FLUID OVERLOAD AND EDEMA

Interventions:

• TAKE MEDICATIONS PER PHYSICIANS ORDERS
• REPORT ANY ADVERSE EFFECTS (DEHYDRATION, HYPOTENSION, MUSCLE CRAMPS, ETC)
• DIETARY TO UPDATE PREFERENCES
• SPEECH THERAPY TO EVAL AND TX PER PO
• MONITOR AND RECORD MEAL PERCENTAGES

YOU STILL NEED TO CARE PLAN: