Help with Care Plans!!! What all to care plan???

[Illusion_mbk]

What all do you care plan on a LTC resident? I am reviewing care plans and trying to figure out what state looks at when they review care plans. Does anyone have any care plans they can post? What are the main areas you care plan?

Thank You

[rapkeygurl]

yes and in texas now they want you careplan PLUS all the risk factors and disease processes and advanced careplanning etc.. etc etc...

[achot chavi]

.. I recently have added a careplan for anyone that does NOT take a flu shot -- YEs they have the right to not have it but we are to offer the risks factors etc.. quarterly. I am careplanning DNR or FULL CODE/Advanced Directives. Wearing briefs at night if they wish. I care plans are super cool.

I care plan ANY and ALL refusals for care- whether its a bath or a blood test or vaccinations- it is worth careplanning it.

[achot chavi]

As a former winner of the Nobel Prize for Care Plans,

What, NINE MONTHS into writing care plans and YOU get the Nobel Prize....:-)

AND I have to be careful not to care plan anything that the nurse's won't do, because then nursing gets cited for not following the care plan. It's crazy.

Yes it is important not to give an unattainable goal...keep goals and interventions within reason and within the facilities abilities-

[123becky]

Everyone in my facility has 7 care plans. !. Information. i put discharge plan, code status. MD visits. Pod visits, DDS, Ocular visits. Ability to self medicate, elopement risk. Next is COGNITIVE FUNCTION/COMMUNICATION, THEN ADL SELF PERFORMANCE/ RISK FOR FALLS, CONTINENCE / SKIN INTEGRITY, NUTRITION/HYDRATION, MOOD/BEHAVIOR, THE POTENTIAL FOR INFECTION. I manage to cover about everything this way. It is easy to follow. & I update as needed. I follow the RAPS to the care plan. Haven't had any problems Yet. I have heard that some facility can have 20 to 30 separate care plans. How the heck can they be followed & updated? Back in the early MDS days a surveyor told me to keep it simple, it will get done.

[Nascar nurse, ASN, RN]

Everyone in my facility has 7 care plans. !. Information. i put discharge plan, code status. MD visits. Pod visits, DDS, Ocular visits. Ability to self medicate, elopement risk. Next is COGNITIVE FUNCTION/COMMUNICATION, THEN ADL SELF PERFORMANCE/ RISK FOR FALLS, CONTINENCE / SKIN INTEGRITY, NUTRITION/HYDRATION, MOOD/BEHAVIOR, THE POTENTIAL FOR INFECTION. I manage to cover about everything this way. It is easy to follow. & I update as needed. I follow the RAPS to the care plan. Haven't had any problems Yet. I have heard that some facility can have 20 to 30 separate care plans. How the heck can they be followed & updated? Back in the early MDS days a surveyor told me to keep it simple, it will get done.

This would not work for me. How would you include some of the major disease processes, ie: IDDM, or use of anticoagulant meds, use of oxygen, HTN (which our survey team is on a kick about!).

[amylpn24]

Exactly what was said previously. Do not care plan for the state, care plan for the resident. You will never master what the state is looking for because, A) It varies B)It depends on the surveyor and what type of mood they are in.

In a nutshell, care plan problems or potential problems. Do not care plan diagnosis, the doctor has already directed the plan of care for those. Do not care plan medications unless you are care planning polypharmacy or psyhcotropics. If the patient is recieving coumadin, prednisone etc.; care plan this under skin integrity - ie: potential for bruising, poor wound healing, skin tears etc.

Care plans must be written in simple form. In a format that a CNA can read and understand. Hope this helps.