A Guide to Resident Assessment Protocols (RAPs)
and Interdisciplinary Care Plans.
Comprehensive Care Planning for
Long Term Care Facilities:
Plans
By Holly F. Sox, RN, RAC-C
Volume 1
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 AANAC for providing a foundation of knowledge and
training, and a network for NACs 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 graduated Magna cum laude with a B.S. in Nursing
from the University of South Carolina in 1988. After graduating,
she has worked as an MDS Coordinator, Clinical Nurse, Special
Procedures Nurse, Office Nurse, as well as a Staff Nurse. In
2003, she was awarded NAC of the Year by the American
Association of Nurse Assessment Coordinators (AANAC).
Currently, Holly serves as the Resident Assessment Director at
J F Hawkins Nursing Home in Newberry, South Carolina and as
Clinical Editor for Careplans.com.
TABLE OF CONTENTS
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 79Introduction 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. Nutritional 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 No 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. Nutrition- Potential or Actual Nutritional Problem 20. Nutrition- Obesity
21. Pain
22. Physical Restraints
23. Pressure Ulcer- Potential or Actual
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. HHNK (Hyperglycemic Hyperosmolar Non 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 Neurological 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
PLAN OF CARE
Problem(s) Goal(s) Approach(es) Dept Review
Robin Technologies Inc. 670 Lakeview Plaza Blvd., Suite J. Worthington OH 43085 614-888.3001 www.robintek.com 2004 careplans.com
Resident Name ID# Room # Physician
Behavior problem: wandering related to * Alzheimers disease * Other dementia * CVA * Delirium * New environment * New 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. 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. N N N ALL ALL ALL ALL N,SW,ACT ACT ACT N HSK