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Comprehensive Care Planning for Long Term Care Facilities: A Guide to Resident Assessment Protocols (RAPs) and Interdisciplinary Care Plans.

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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

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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.

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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 79

Introduction 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

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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

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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

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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

SA

M

PL

E

References

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