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What is a Person Centered Care Plan?. Directed by the person it is about Written in a language everyone is able to understand Focuses on a person’s strengths Recognizes the issues of the moment. Q: Why Should We Change to “I” Care Plans? . A: To Maintain Personhood.
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What is a Person Centered Care Plan? Directed by the person it is about Written in a language everyone is able to understand Focuses on a person’s strengths Recognizes the issues of the moment
A: To Maintain Personhood • Attachment- bonding to someone • Comfort- the feeling of security • Inclusion- to be part of the group • Occupation- involved in life in a personally significant way • Identity- to know ones self
Q: So How Do I Get Started? • Start with your elders • Create a team • Include your surveyors • Develop a time line • Make it realistic • Don’t give up
h. Safety notes i. Skin care j. Nutrition k. Physical needs l. Activities m. Pastoral needs n. Discharge plan • Social History • Communication/Memory • Well-being • Mobility • Personal care • Bladder function • Bowel function
Meds- why given? • Diagnosis..specify terms patient would use Ex: sugar problems, heart problems • Physicians orders • Nurse notes • Monthly summary • Activity notes • Social Services notes • Labs, x-rays • Dietary- diet, review with client likes and dislikes, monitor wt and intake • Behaviors monitored • Wounds • falls • Hospital stay • Restraints • Prior care plan • Triggers MDS • Vital signs
Combative • Make-up • Nails • Massage therapy • Special bath procedures • Where they eat • % of meals • Water pitchers in room 24 hours a day + additional drinks • Diet • Church • Hobbies, TV, sports, gardening, socializing, and reading • Family involvement • Psych visits
Social History: I was born in Houston, Texas in 1930. I have one living brother and one deceased. I completed high school and received my Bachelor’s Degree and worked in construction. My wife and I were married for 30 years until she recently passed away with cancer earlier this year. I miss her dearly. I was previously living at home with my wife in Lake Jackson, Texas, until I had a fall in my home. I was not found until 12 hours after my fall. My fall ultimately resulted from a stroke. My wife rehabilitation at the hospital for a short time and was discharged. My doctor ordered me to continue with therapy, so I came to Country Village Care to get rehabilitation and continuous care. After I completed therapy, my family and I decided to make Country Village Care my new home.
Communication/Memory: I have some trouble with my short-term memory. I am forgetful and become a little confused at times, requiring redirection from the staff. I have a history of dementia which contributes to my memory loss, as well as the stroke I had. I speak clearly but need a little extra time getting my thoughts out sometimes. I have trouble understanding others and need others to speak slowly in simple terms. Goal: I want to remain alert, aware of my surroundings with the redirection and assistance of others, expressing my wishes and needs to others.
Well-being: I am a very pleasant person to be around. I enjoy being around others and visiting. I have made many friends at my new home and enjoy taking part in the activities and parties offered to us. I recently lost my wife to cancer and am still dealing with her loss. She was very dear to my heart and I miss her. I try to stay involved in activities, and out and about to help with my loss. My family visits often which helps. I enjoy helping others and volunteering. I may need reminders and assistance because of my memory loss and confusion at times. Please provide me with assistance as I need it. I may try to reach things or bend down to pick things up off of the floor which puts me at risks for falls. Please redirect me and provide me with distraction or an activity to divert my attention. Goal: I want to remain active, cope with the loss of my wife, and attempt safe transfers with the assistance of others in my home.
Mobility: Ambulation: I had a stroke which left my left side weak. Sometimes I walk with my walker too fast or do not pay attention to where I’m going, so please stop me and remind me to slow down and watch where I am going. Transfers: I transfer by myself. I did work with restorative therapy to increase my strength until the first part of October. Positioning: I can reposition myself in bed or chair to make myself more comfortable. Assistive Devices: I use a rolling walker to assist me with walking. I sometimes forget to use it so please remind me. Mobility Goal: I want to remain active and independent.
Personal Care: Vision: I wear glasses everyday to help me see well. If I have forgotten to put them on, please remind and encourage me to wear them. I also need someone to help me keep my glasses clean everyday. Hearing: I don’t have any trouble hearing others at this time. If I begin to have problems, I will let my nurse know. It may take me a few minutes to respond because I have Alzheimer’s disease. Oral Care: I do not have any teeth. If I have any problems with my mouth, I will let my nurses know. A.M./P.M. Care: I can do my morning and evening care myself.
Personal Care (continued): Dressing: I need one person to assist me with my dressing because of my left-side weakness and my forgetfulness. Toileting (Transfer/Assist): I can transfer on and off the toilet by myself. Bathing: I need someone to assist me with my showers. I get a shower three times-a-week. ADL Goal: I want to continue to be as independent as I can with walking and grooming.
Bladder Function: I wear a brief because I am incontinent. Goal: I want to continue to remain dry and comfortable.
Bowel Function: I recognize when I need to have a bowel movement and go to the bathroom by myself. If I become constipated, I tell the nurse and she gives me a medication. Goal: I want to remain free from constipation and independent with toileting.
Safety notes: I have a slight tremor because of my Parkinson’s disease, left-side weakness from a stroke, and I have some confusion and forgetfulness because of Alzheimer’s disease. I stumble or walk too fast sometimes and forget to use my walker and will try to pick things up off of the floor. I have had falls and I am still at risk for falls. I need reminding to use my walker, slow down and not pick things up from the floor. I need help keeping my room organized and free from clutter. Goal: I want to be free from falls and injury.
Skin: I don not have any problems with my skin. If I do develop a skin problem, I will tell the nurse or a certified nurse’s aide will. Goal: I want to have skin that remains free from breakdown.
Nutrition: Diet: I do not have any teeth and I have a little difficulty swallowing. My meals are mechanical soft with ground meat. I recently loss some weight, so now I have some additional nutrients in my food. I also receive a house shake three times a day. Dining Room: I have a reserved seat in the courtyard dining room. I eat in this dining room every meal. Eating Habits: I eat 100% of my meals. I also eat snacks in between meals. I keep snacks in my room. When Activities has snacks, I will eat some then as well. Nourishments: The nurses and dieticians monitor my labs and my weight. My weight has now decreased. I take a multi-vitamin everyday. Goal: I want to maintain my weight.
Physical Needs: Pain Management: If I have any pain, the nurse will give me pain medication. Fluid Maintenance: I forget to drink fluids sometimes and need to be reminded. The staff keeps my water pitcher filled 24 hours a day and offers me additional fluids throughout the day. I do not have any problems with dehydration. Goal: I want to be free from pain and dehydration.
Activities: I enjoy attending many of the activities offered such as sittercise, parties, movie and popcorn, Bible study, church services, fishing shows, NASCAR races, coffee and donuts, bingo, good humor cart, trivia games and visiting with friends and family. Goal: I want to remain active and social, attending 3-5 activities per week.
Pastoral: I am of Baptist faith. I enjoy attending Calvary Baptist Church services and Bible study. Discharge Plan: I was living at home with my wife until I had a stroke and fell. I needed extra care and therapy, so I came to Country Village Care for rehabilitation. After I finished therapy, I decided to make CVC my new home. My family and I are very pleased with the care I receive and have no plans on leaving.
