Individualized Care Plan Development Guide for Residents with COVID-19

Individualized Care Plan Development Guide for Residents with COVID-19 Directions: Use the Nursing Process and accompanying care plan prompts table (below) as a guide to develop a care plan for residents who have COVID-19. The care plan should remain individualized, person-centered, and be based upon how COVID-19 is affecting the resident and their health and well-being. Note: the information is not all-inclusive, nor is it intended to replace medical directions and orders for care, or facility policy and procedures for care plan content. assessment nursing diagnosis Identify the signs and symptoms the resident with Identify how the signs and symptoms of the COVID-19 COVID-19 is experiencing. Common symptoms include infection are impacting the resident. Address the risk but are not limited to: fever; symptoms of dehydration, of more severe respiratory complications, even if the such as increased confusion and headache; and resident is currently only experiencing mild symptoms. compromised respiratory status, including cough, shortness of breath, and impaired oxygen exchange. evaluation planning Determine if the outcomes Establish the care plan the resident experienced goals, incorporating the achieved the care plan resident’s wishes and goals. The COVID-19 virus preferences. can cause rapid decline; therefore, findings from the nursing assessment, performed at the bedside, implementation may trigger the need to evaluate and update the Identify the medical, nursing, respiratory care plan frequently. therapy, and other interventions that will be implemented to care for the resident with COVID-19. ©2020 AAPACN | The information presented is informative and does not constitute direct legal or regulatory advice. | AADNS-LTC.org Released April, 2020 care plan prompts How is COVID-19 What are the goals of What can be done to help affecting the resident? care for this resident? the resident achieve the goals? Use information gathered from Goals are measurable and the nursing assessment and other time-specific, but they are also Include all interventions that will be sources of data to formulate the relevant and centered on what is implemented to help the resident nursing diagnosis or the problem. important to the resident and/or and support the goals of care. • Resident has diagnosis of resident’s representative. • Management of symptoms may COVID-19 and is experiencing • Maintain airway and oxygen include but is not limited to: respiratory complications exchange as evidenced by… – Administration of oxygen including impaired oxygen Note how this will be measured – Use of BIPAP or CPAP exchange… Describe the signs (e.g., respiratory rate, O2 sat at – Turn, cough, and deep and symptoms the resident is minimum threshold). breath exercises experiencing. • Resident will be hydrated as – Use of incentive spirometer • Resident is dehydrated as evidenced by… Note how this – Administration of IV fluids a result of COVID-19… will be measured (e.g., moist – Use of antipyretics Describe the signs and mucous membranes, light – Maintaining an environment symptoms the resident is colored urine). conducive to rest and sleep experiencing. • Resident will be comfortable – Oral care • Resident is at risk for pain as evidenced by… Note how – Massage and discomfort… Describe this will be measured (e.g., pain – Turning and repositioning specifically why the resident is severity level per assessment). schedules at risk. • Resident will indicate when – Isolation with droplet and • Resident is at risk for additional support is needed to contact precautions loneliness, anxiety, and address feelings of loneliness, – Phone calls, emails, social sadness related to isolation anxiety, and sadness. media or other cyber precautions implemented due goals contact with loved ones problem to COVID-19. – Phone calls, emails, social media, or other cyber interventions contact with minister, priest, rabbi, or other spiritual leaders – One-on-one visits with staff reading, playing puzzles, conversation, or other resident-desired activity – Activities to maintain engagement and provide a calming atmosphere. Music, aromatherapy, favorite movies, audio books, or another activity preferred by the resident • Follow facility policy for formatting and content expectations of care plan interventions, i.e. inclusion of details for physician orders; frequency of bedside care; other. ©2020 AAPACN | The information presented is informative and does not constitute direct legal or regulatory advice. | AADNS-LTC.org Released April, 2020.

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