<p> GOAL: No complications______Skin status:______I&O:______Activity Pursuits Altered ______Monitor for s/s bleeding:______Weight/Appetite:______GOAL: Activities as desired until discharge Protect from injury:______Complications: fatigue, attitude, apprehension, achieved______Labs/ Meds as ordrered:______N/V:______Introduce to activities offered______Pro times as ordered:______Pain management:______Interview to interests______Safety measures:______DATE:_______________________________Cardiac__________________GOAL: No complications____________DATE: ____________Meds_____________Behavior Symptom______Assess heart rate, B/P, resps______DATE: ______GOAL: Fewer symptoms ______Monitor for edema______Diet restrictions:______ADL Decline______Redirect by:______Elevate:______GOAL: Improve ADL skills to achieve Discharge Assess Internal Contributors:______O2:______Plan______Assess External Contributors:______Monitor endurance/complications____ Rehab:______R/O Delirium: ______Rehab:______Grooming:____________DATE:______Dressing:______Dining:___________________CVA/Stroke Rehab______Ambulation:____________GOAL: Achieve Rehab goals for Siderails:______DATE:______discharge______Rehab:______Transfer:______Toileting:______Bladder Training/Foley______Grooming:______DATE:______GOAL: Increased continence to achieve Discharge Dressing:______Plan______Dining:______Amputation: BK or AK _____ Encourage fluids______Transfer:______GOAL: Heal without complications _ Foley Cath Care:______Ambulation:______Toilet type:______Toileting:______Assess wound site______Scheduled toileting:______Siderails:______Rehab:______DATE:______Nsg:______Bladder training:______Restorative:______R/O cause of incontinence:_______Cognitive Decline______Dressing: ______I&O:______GOAL: Establish daily routine______Monitor for depression______DATE:____________Task segments____________Bowel Training/Altered Bowel Cue as needed______DATE: ______Elimination______Reality orientation PRN______GOAL: Establish bowel routine_____ Offer choices______Anemia ______Visual cues:______GOAL: Minimize complications_____ Dietary referral:______Speech therapy:______Meds as ordered:____________Monitor for complicaitons______Bowel training:____________Monitor nutritional intake______DATE:______Labs:______Monitor elimination pattern, color, consistency, V.S. each shift:______odor______Dr. ________________________DATE:__________________Room: ______Adm.#______DATE: ______</p><p>Resident: _______Cancer______GOAL: Achieve physical & mental comfort______ Anticoagulant Therapy______Vital signs:______Hospice:______INITIAL CARE PLAN</p><p>_Communications Decline______GOAL: No complications______GOAL: Increase ability to ______Cast:______communicate______Meds:______Positioning:______Communication techniques:______Diet:______Pain:______Speech Therapy referral:______Monitor S/S Hypo/hyperglycemia____ Safety Procedures:______Evaluate hearing loss:______Accuchecks as ordered:______Rehab:______Check ears for wax:______Labs as ordered:____________________________________________________________DATE:____________DATE:______DATE:_______G.I. Disorder_______Discharge Planning______GOAL: Decreased symptoms_______Dehydration/Risk of______GOAL: Achieve discharge as planned ______GOAL: Consume adequate fluids______Nutrition:______Interview Resident______Meds:______I&O______Interview Family______Bowel sounds:______Determine likes/dislikes:______Arrange Post-discharge______Monitor Bms for consistency, color, Offer fluids between meals:____________odor______Monitor for dehydration:____________I&O______Specific Gravity________________________________________________DATE:____________DATE:______DATE:_______Fall/Safety Risk______GOAL: No injury falls_______Infection Alert______GOAL: Resolve infection_______Delirium Present______Assess for contributors: Bps standing, sitting, pain, need to void, ______GOAL: Resolve Acute Condition____ meds gait____ Monitor for S.S. for infections______Encourage to use call light______Tx:______Meds:______PT referral______Wound status and progress______R/O for acute illness/Labs:______Instruct on safety measures____________Orient PRN______Adaptive Device (OT)____________Assess for pain/constipation/UTI_____ ____________________________________DATE:__________________DATE:_____________Feeding Tube______DATE:______GOAL: No complications_______I.V. Therapy_______Dental Problems______GOAL: No complications______GOAL: Resolve______I&O______T.F. Order______I&O______ Meds/TX's:______Speech Therapy referral______I.V. orders:______Monitor appetite:______Assess for placement:____________Assess oral cavity:______Labs:______Weigh every:______Evaluate need for dental exam:____________Monitor for complications________________________________________________DATE:__________________Room:______Adm.#______DATE:______DATE:______Resident:_______Fracture/Fractured Hip_______Diabetic Alert______GOAL: No complications______INITIAL CARE PLAN _Mood Symptoms_______Pain_______Psychotropic Drug Use______GOAL: Decreased symptoms______GOAL: Experience less pain______GOAL: Benefit without side effects______Activities:-______Meds:______Monitor for side effects:______Depression scale:______Assess for non-drug interventions____ Meds:______Non-drug interventions:______Trial reduction:______Likes to:______Monitor Behavior or Mood Symptoms S.S. 1:1______Monitor pain q shift__________________Assess pain tolerance________________________________________________DATE:______DATE:______DATE:______</p><p>_Nausea and Vomiting_______Physical Restraints_______Renal Failure with Dialysis____ GOAL: Resolve______GOAL: Experience no complications_ GOAL: Experience no complications______Intake:______Assess for alternatives______Weigh:______Monitor for dehydration:______Restraint reduction initiated:______Assess for S/S infection, hypovolemia Document frequency, amount, color/consistency of Restraint order:______Observe for S/S bleeding______emesis______Alternatives:______Dialysis schedule______Meds:____________No BP in shunt arm____________________________________________________________DATE:______DATE:______DATE:______</p><p>_Nutrition_______Pressure Sore/Skin at Risk____ _Respiratory/Tracheostomy____ GOAL: Achieve/maintain weight of:_ GOAL: Prevent/heal pressure sores_ GOAL: Maintain patent airway______Intake/Appetite______Tx:______Lung sounds/cough sounds/Resp.____ Diet:______Preventive:______O2______Weigh q:______Suction:______S.T. Ref.______Position:______Trach care:______Determine likes/dislikes______Meds:______Supplements:____________Supplements______Wound team referral:______________________________DATE:______DATE:______DATE:______</p><p>_Ostomy_______Psychosocial Well-being_______Seizure Disorder______GOAL: Participate in ostomy care___ GOAL: Express satisfaction______GOAL: Will not injure self or others______Ostomy protocol______Orient to facility:______Seizure precautions______Teach self-care______Activities:______Meds______Monitor for complications______1:1 by Social Service______Side rails:______Monitor for infections at ostomy site__ Customary routine:____________________________________________________________________________________DATE:______DATE:______DATE:______</p><p>Dr.______Resident:______Room:______Adm.#______INITIAL CARE PLAN</p><p>_Skin Condition (non-decub)____________GOAL: Resolve______I&O:____________Status of continence:____________Treatment:______Meds / side effects:______DATE:______Monitor for infection:______Urine color, frequency, burning______Preventive:__________________Positioning:____________GOAL: __________________________________________DATE:________________________DATE:_______Vision Altered____________GOAL: Participate in ADL's to______optimal _______Terminal Care______level____________GOAL: Death with dignity______Verbal cues:____________Meds:____________Meds:______Eye exam:______DATE:______1:1______Wears______Hospice______Post-surgical care:____________Pain Manaagement:____________GOAL: ______Comfort measures:____________Treatment:________________________DATE:________________________DATE:__________________GOAL: _______________________________TPN Therapy__________________GOAL: No complications____________DATE:____________Monitor for infection & complications ____________Line type:____________GOAL: ______Flow rate:____________TX protocol:__________________Monitor nutriton:______DATE:____________I&O____________________________________GOAL: ____________DATE:_____________________________________URI/Pulmonary Disease____________DATE:______GOAL: Resolve__________________Lung sounds/resp:____________Dr.______Cough status:____________Level of consciousness:____________Tx:______DATE:______Suction:______O2______Room:______Adm.#________________________GOAL: ______DATE:__________________Resident:_____________UTI Alert____________GOAL: Resolve____________</p>