Staff to perform ADL's every shift with special mouth care.Clean after each episode of incontinence.Turn at least Q two hours/reposition.Monitor/and report all red areas.Monitor for tolerance of feeding /report diarrhea or vomiting.Monitor for
dry skin,dry mouth, poor skin turgor,fluid intake.Monitor lab/wts.Report loss or abnormals promptly,give auditory stimulation activities as tolerated.Socialization visits daily, staff to check resident at least every Q2hours and give verb
al stimulation.Monitor V/S ,weights,labs report abnormals to MD promptly.
hotos/mementos of past events. Assit in emergencies.Maintain pleasant interaction with resident which will reassure when confused. Encourage reminiscence and small group interaction when possible.Give verbal reminders which can help
Resident will receive Reality orieintation while daily care is given. Involve resident in enjoyable activities which orient to reality /don't depend on orientation. Encourage visitors to bring in p
in orientation.Post activity schedules. Monitor weights and resident appetite.
Reality Orientation while giving daily care. Involve resident in enjoyable activities which orient to reality and don't depend on orientation. Encourage visitors to bring in photos and mementos. Keep environment free of hazards
. Assist in emergencies.Pleasant interactions which reassures resident when confused. Explain all procedures.Encourage small group activity.Post activity schedules and assure that resident gets to activitie
Resident will receive reality orientation during daily routine care by staff. Involve resident in enjoyable activities which orient to reality and don't depend on orientation. Encourage visitors to bring in photos. Keep environment free of hazards
. Assist resident in emergencies.Explain all procedures. Give resident verbal reminders which assist in orientation.Post all activity daily/weekly/monthly. Monitor resident interaction with others.
Assist resident in decision making by giving simple choices.Assure that resident wishes are understood by listening when resident tries to talk. Encourage he/she in choices of care,clothes and activities. Keep environment free of hazards
/always assist in emergencies big or small.Pleasant interaction by all staff . Break tasks up into small shorter segments.Give reality orientation while giving daily or routine care. Verbal reminders while giving care. Monitor w
eights and appetite.
Completely assess resident to determine cause: Report all lab findings to MD. Calm approach and environment maintained always. Have resident invloved in low stress activities. Reality orientation during daily
care. Verbal reminders often,with pleasant interaction which reassures resident when confused. Encourage reminiscence and small group activity as tolerated.
Assess resident to assist MD to determine cause. Give reality orientation while rendering care. Monitor fluids intake,skin turgor,and dry mouth. Keep calm approach and environment. Reassurance to resident and fami
Communicate by: Involve resident in activities which don't depend on hearing:parties,crafts,games,sma
ll groups. Socialization visits if resident not attending activities regularly. Speak facing resident in simple phrases. Encourage resident to choose activities.
Use short phrases and questions which require yes or no answers. Use gestures as necessary. Assess for adequate communication needs. Also give reassurance and have patience when resident attempts to communicate with any
staff. Monitor resident for changes in his/her condition. Keep environment safe with call light answered promptly.Also try to involve resident ,in activities that he/she can relate too without verbalizing,like music,mov
ies,parties.
Use short phrases and questions which require yes or no answers. Use gestures as necessary. Assess for adequate communication. Reassurance and patience when resident attempts to communicate or doesn't understan
d. Monitor resident for changes in condition.
Staff will use short phrases and questions which require yes or no answers.Use gestures as necessary. Involve in activities which don't depend on residents ability to communicate.e.g music,movies
Monitor resident for changes in condition.Assess V/S labs results,medications appetite, level of consciousness to assist MD. Reassurance and patience when resident attempts to communica
Keep environment free of small objects on floor, e.g. very hot liquids, and or toxic liquids. Involve resident in auditory activities e.g. exercise music, parties. Always explain location of food
on tray when served. Always explain all procedures when done ac /pc. Announce self when entering/leaving resident room. Remember special inhouse precautions in emergencies. Encourage independence in ADL's as tolerated. Reorient
resident if belongings are moved or change about in personal environment.
Keep environment free of small objects on floor . Involve in auditory stimulation daily. Explain location of all food on tray when served. Always explain all procedures. Always announce self when enteri
ng resident room. Have ready special precautions in emergencies. Encourage independence of all ADL's as tolerated.
Encourage independence with minor assistance or verbal reminders. Praise when independence is attempted or done. Have call light near resident and answer promptly.Remind and assist as necessary in turning every two hours.
Monitor skin for redness. Skin assessment upon admission q 3months rcp meetings and prn. Apply dialy skin care and pressure reducing mattress when needed.
Call light available and answered promplty. Explain all procedures and purpose. Encourage independence with minor assistance. Praise when independence is attempted or done. Transfer in and out of bed as ne
eded.
Explain all procedures and purpose. Encourage independence with minor assistance. Praise when independence is attempted or done. Have call light near resident and answer promptly. Remind and assist as necessary i
n turning every two hours.Monitor skin for redness/Monitor and assist with transfers as needed.
Encourage independence with minor assistance. Praise when independence is attempted or done. Take out of room as requested and at least daily unless resident refuses or is ill. Call light available at all time
s. Assist to move around facility as needed. Encourage independence in self-propelling when in w/c.
Explain all procedures and purpose. Encourage independence with minor assistance. Praise when independence is attempted or done. Encourage resident to pick out own clothes. Dress and change as needed.
Assure proper clothing is available.
Encourage independence with minor assistance. Praise when independence is attempted or done. Open all cartons and plastic,butter,bread as needed. Prompt to eat if needed. Monitor for food preferences.Mon
itor weights and appetite. Feed resident slowly. Encourage to eat all food. Adhere to food preferences.
Explain all procedures and purpose. Encourage independence with minor assistance. Praise when independence is attempted or done. Take to bathroom or put on bedpan every two hours as requested.
Have call light close and answer promptly. Take to the bathroom during day as needed.
Explain all procedures and purpose. Encourage indepencednce with minor assistance. Praise when independence is attempted or done. Monitor for hygiene needs and render as needed each shift.
Oral hygiene to be done Q shift as needed. Encourage choices in care. Setup and assist or prompt as needed.
Explain all procedures and purpose. Encourage independence with minor assistance. Praise when independence is attempted or done. Shower per schedule and as needed or requested.
Turn and reposition Q 2hours. Use pressure reducing devices. Encourage 80-100% of diet. ROM by staff for red areas and report promptly. Keep skin clean and sheets wrink
le free. Room activities and visits for stimulation when in staying in bed. Call light handy and answered promplty.
Have call light available and answer it promptly. Monitor for safety in mobility. Assist as needed. Visual check at least Q two hours and reposition.
ROM by staff. Monitor for pain or increased stiffness. Use positioning devices. Reposition Q 2hours. Activities which don't depend on
dexterity:Music,parties,movies. Keep contracted area clean and odor free.
ROM by staff. Monitor for pain or stiffness. Use positioning devices.Reposition Q 2hours. Activites which don't depend on dexterity-music,movies,games. Pressure reducing mattress.Monit
or appetite and feeling ability. Monitor appetite and feeding ability. Monitor for negative expressions of self worth. Assist in ADL's and mobility as needed.
ROM by staff. Monitor for pain or stiffness. Use positioning devices.Reposition Q 2 hours. Activities which don't depend on dexterity-music, movies,parties. Pressure reducing mattress.
Monitor for negative expressions of self worth. Assist in ADL's and mobility as needed.
ROM by Staff. Monitor for pain or stiffness. Use positioning devices as needed. Reposition Q 2 hours. Activity which don't depend on d
exterity: Music/movies/parties/games.
Assist in grooming,eating and hygiene as needed. Encourage independence. Encourage activities which don't depend on hand dexterity-music,parties,games. Monitor ability to eat and asses
for use of adaptive equipment if needed.
ROM by staff while giving care. Monitor for pain or stiffness. Use positioning devices as needed. Reposition Q 2 hours. Activities which don't depend on dexterity of legs: like music,games,drawings.
Monitor skin for breakdown. Pressure reducing mattress.
Encourage OOB daily.Call light near resident and answered promptly. Staff to assure resident receives assistance when needed. staff to instruct resident to use hand rails. Staff to instruct resident to asD
k for assistance. Staff to respect rights to independence. Staff to assure environment is free of wet spots and small items placed low on floor.Staff to assure lighting is appropiate.Assure resident gets to activitie
s and out of room as needed.
Encourage independence with minor assistance. Praise when independence is attempted or done. Assist in repositioning every two hours. Pressure reducing mattress. Positioning devices as needed. A
ssure resident gets to activities and events as needed. Assure resident receives asisstance in eating if needed.Position resident to assure highest functioning.Call light available and answered promptly.H
Assure balance in wheelchair. Assist to transfer as needed. Assist to turn Q 2 hours as needed. Call light near and answered promptly. Assisted as needed to get around facility. Monitor for skin breakdown. ROM
for skin breakdown. ROM by staff giving care. Pressure reducing mattress.
Encourage resident towards independence. Praise resident when accomplishment is attained.
Assist MD in determining why functioning has been lost by monitoring medications,fluid intake, skin turgor, appetite,labs,weights,ability to move,level of consciousness,or recent environmental changes. Assess for rehabilitation. Encou
rage resident for rehabilitation.
Clean resident after each episode of incontinence. Monitor and report all red areas. Cheerful dialogue with resident while cleaning to encourage maintained self esteem
. Call light available at all times.
Clean after each episode of incontinence. Monitor and report all red areas. Cheerful dialogue with resident while cleaning to encourage maintained self esteem
. Call light available at all times.
Take resident to the bathroom at designated times and PRN: Designated Times: R
Praise when successful,cheerful dialogue when cleaning after episode of incontinence. Change position at least every two hours.
Call light available and answered promptly.
Monitor external catheter and change catheter or bag when needed. Monitor urine for sediment,cloudy,odor,blood,amount. Report any of the above or fever promptly to MD.
Encourage fluids. Monitor lab. Turn Q 2 hours and monitor skin for redness. Good peri care.
Monitor indwelling catheter and change catheter or bag when needed. Monitor urine for sediment,cloudy,odor,blood,amount. Report any of the above or fever
promptly to MD. Encourage fluids. Monitor lab. Turn Q2 hours and monitor skin for redness. Good peri care.
Monitor intermittent catheter and insert catheter as needed. Monitor urine for sediment,cloudy,odor,blood. Report any of the above or fever promptly to MD. Encourage fluids.
Monitor lab. Turn Q 2 hours and monitor skin for redness. Good peri care.
Clean after each episode of incontinence. Monitor and report all red areas. Cheerfull dialogue with resident while cleaning to encourage maintained self esteem.
Call light available and answered promptly. Monitor resident at least every two hours for INC. Pressure reducing mattress. Turn Q 2 hours and reposition with devices.
Clean resident after each episode of incontinence. Monitor and report all red areas. Cheerful dialogue with resident while cleaning to encourage maintained self esteem
. Incontinent pads-check and change when wet Q 2 hours. Turn and reposition with position devices Q2hours. Give good peri care.
Monitor: Treatment as ordered. Report abnormal symptoms to MD promptly.
Talk to resident while performing treatments to help maintain self-esteem.
Cheerful dialogue while rendering ostomy care. Ostomy care as needed to prevent odors. Monitor ostomy site for swellinga
,pain,or redness and report promptly to MD. Monitor output for:
And report promptly to MD:
Monitor medications,labs,and environment to assist in finding out cause for decrease in functioning. Initiate bladder retraining program: a.Take to the bathroom or offer d
bedpan at least every ____hours.b.Praise when successful,clean when incontinent.c.Cheerful dialogue while giving INC care to help promote self-esteem.d.Evaluate and revise program weekly.Monitor labs and report abnomals promptly
to MD. Monitor output for amount,frequency. color,consistency,and blood \ report abnormals to MD.
All staff to encourage resident to socialize. Encourage activities of choice and interest: Encourage socialization with roo
mmates. Room visits when resident stays in room for 1:1 socialization. Cheerful dialogue with resident while giving care.
All staff to encourage resident to socialize. Encourage activities of choice.Encourage socialization with roommates. Room visits when resident stays in room for 1:1 socialization.5.1:1 discussions
with resident with staff interventions to assist in unhappiness.
All Staff to praise resident over accomplishments. Staff to communicate with resident about: If resident wants to. i
Encourage activity attendance of choice and interests. Room visits if resident doesn't attend activities. j
Monitor appetite.
BEHAVIOR INTERVENTIONS: When resident is upset,staff to try to alter residents enivironment take to activities,on walk. Encourage resident to be involved in acitivities. Listen attentively and attempt tn
o resolve or discuss area of upset. Encourage 80-100% of diet and fluids. Monitor weights,appetite,fluid intake,labs,medications to assist physician in finding clinical cause. Notify MD
if it interferes with functioning.
BEHAVIOR INTERVENTIONS: When resident is upset,staff to try to alter residents environment take to activities,on walk, give support and reassurance. Encourage resident to be involveq
d in activities of choice.Listen attentively and attempt to resolve or discuss area of upset. Notify MD if interferes with functioning. Monitor labs,appetite,medications,and enivironment to assist MD
if determining cause.
BEHAVIOR INTERVENTIONS: Assist in reorientation to room. Encourage group activities and attempt to keep resident occupied. Assist in orientation to facilit
y. Monitor resident location with visual checks at least Q2 hours. Put familiar items in resident's room to assist them in identifying room. Monitor appetite and eating.
BEHAVIOR INTERVENTIONS: Always approach resident calmly and unhurriedly. Speak in a calm voice. Explain all procedures and reason before performing. Encourage resident to perform inv
dependent ADL's. Listen attentively. Attempt to refocus behavior to something positive when resident is exhibiting verbally abusive behavior. When resident is demonstrating an abusive out burst, calmly as
k resident to take some deep breathes and calm down. Monitor weights and appetite.
BEHAVIOR INTERVENTIONS: Always approach resident calmly and unhurried.Speak in a calm voice.Explain all procedures and reason before performing.Encourage resident to perform independent ADL's.Listen attentively.Attempty
to refocus behavior to something positive when resident is exhibiting abusive out burst,calmly ask resident to take some deep breathes. Encourage resident to discuss interest or concerns. Involve f
amily in care if possble or available. Monitor weights and appetite.
BEHAVIOR INTERVENTIONS: Always approach resident calmly and unhurriedly.Speak in a calm voice.Explain all procedures and reason before performing. Encourage resident to perform independent ADL's. Listen attent|
ively. Attempt to refocus behavior to something positive when resident is exhibiting inappropriate behavior. Encourage and asist resident to help staff in mutual problem solving of cause. If approp
riate give care late when resident is clamer. Encourage activities of resident choice and preference.
BEHAVIOR INTERVENTIONS: Always approach resident calmly and unhurriedly. Speak in a calm voice. Explain why care is needed. Encourage resident to perform independent ADL's and decisions concerning timing of c
are, clothes to wear, what activities to attend. Encourage and assist resident to help in problem solving. Encourage resident to discuss interests or concerns. Involve f
amily in care if possible or available. Call MD if behavior interferes with medical needs.
BEHAVIOR INTERVENTIONS: Always approach resident calmly and unhurriedly.Speak in a calm voice. Explain all procedures and reason before performing. Encourage resident to perform independent ADL's and decisions
concerning timing of care,clothes to wear,what activities to attend. Listen attentively. Attempt to refocus behavior to something positive when resident is exhibiting Mood swings. Involve f
amily in care if possible or available.
Assist MD in determining why behavior changes have happened.Monitor medications,appetite,labs,weights, level of consciousness,V/S behavior manifestations noted. BEHAVIOR INTERVENTIONS:
Always approach resident calmly and unhurriedly. Speak in a calm voice.Explain all procedures and reason before performing. Listen attentively. Involve f
amily in care if possible or available. Monitor diet and appetite,fluid intake.
Invite resident to activities daily. Remind resident of activities schedule and how they particulary enjoy:
Staff to get up in time to attend activities of choice. Encourage resident to assist in planning the activity program as capable.
Invite to activities daily. Remind resident of activities they particularly enjoy. Room visits when not going to ac
tivities. Respect resident right to refuse.
Invite to activities daily. Remind resident of activities they particularly enjoy. Room visits when not going to ac
tivities. Respect resident right to refuse.
Invite to activities daily. Remind and encourage resident to attend activities they particularly enjoy. Room visits with activity suppli
es when not going to activities. Respect residents right to refuse activities.
Invite to activities daily. Remind and encourage resident to attend activities they particulary enjoy.
Room visits when not going to activities. Respect residents right to refuse.
Consult with resident for activities they prefer.
Medications as ordered :Following time line. Lab work if ordered note all abnormals an report to MD findings. Encourage 80-100 % of diet. Encourage activity and mild exer
cise daily. Monitor for chest pains or abnormal pulses and report to MD.Monitor for 6-8 hours of sleep. Encourage activity attendance.
Medications as ordered. Monitor: Lab work if ordered with abnormals reported promptly to MD. Encourage 80-100% of diet. Encourage activity and mild exercise daily. Monitor for chest pains or abnor
mal pulses and report to MD. Monitor for 6-8 hours of sleep. Encourage activity attendance.
Monitor feet and hands for edema. Encourage resident to be out of bed daily and exercise. Diet and Medications as ordered. Notify MD if edema, chest pains, elevated B/P or shortness of breath occurs.
Lab and Xray as ordered. Encourage Activity attendance.
Medications as ordered. Lad as ordered. Monitor B/P as ordered and notify MD if high or low. Diet as ordered. Monitor for edema,chest pains,he
adache,dizziness,and vomiting and report promptly. Encourage activity attendance.
Medications as ordered.Lab as ordered. Monitor B/p as ordered and notify MD if high or low. Diet as ordered. Monitor for edema,chest pains,headache,dizziness,and vomiting and report promptly.
Encourage activity attendance.
Medications as ordered.Monitor: Lab work if ordered with abnormals reported promptly to MD. Encourage 80-100% of diet. Encourage activity and mild exercise daily.
Monitor for chest pains or abnormal pulses and report to MD. MOnitor for 6-8 hours of sleep. Encourage activity attendance.
Reality Orientation while giving care. Involve in enjoyable activities which orient to reality and don't depend on orientation. Encourage family to visit and bring in photos and mementos. Keep enivronment free
of hazards. Pleasant interaction which reassures resident when confused. Explain all procedures. Encourage reminiscence and small group interaction. Assist in emergencies. Post activity schedule. Monitor d
ietary intake and weights.
Give resident reality orientation while giving care. Involve in enjoyable activities which orient to reality and don't depend on orientation. Encourage family to visit and bring in photos and mementos.Keep environment free o
f hazards. Pleasant interactions which reassures resident when confused.Explain all procedures.
Use short phrases and questions which require yes or no answers. Use gestures as necessary. Reassurance and patience when resident attempts to communicate.Monitor resident for changes in condition. Environment safe with call light
answered promptly. Involve in activities which don't depend on residents ability to communicate:music,movies. Small group and 1:1 socialization. Monitor diet and weights.
Diet as ordered. Medications as ordered.ROM by staff giving care. Monitor vital signs and lab and report abnormals promptly. Invite resident and encourage resident to attend activities daily. Assist
resident in attending to ADL's with special attention to grooming. Monitor for verbalizations of poor self esteem due to physical condition and address issues of residents concern. Monitor weight and appetite. Staff to assist resident
in getting up in time for activities.
Encourage 80-100% of diet with monitoring of feeding ability.Out of bed daily to tolerance with naps as needed. Monitor cognitive status,bladder dysfunction,visual disturbances,visual disturbamces, mental status,and muscular movem
ent for posible signs of disease process and report new occurrences to MD. Invite to and arrange for being out of bed for activities of choice and tolerance. Listen attentively to resident and discuss concerns with resi
dent as needed.
Medications and lab as ordered.Monitor ADL's for assistance and render care as needed. Monitor environment for possible padding of side rails and special chair needs if involuntary muscle movements places resident at risk for inju
ry. Notify MD if involuntary movements increase. Invite to activities which don't depend on dexterity: Music,movies,games.Listen to resident when verbalizing concerns over disease symptoms and address issues raised.Mo
nitor weights and diet.Assure resident is monitored during mealtime if needed.
Monitor resident for episodes of shortness of breath and implement interventions as ordered. Monitor feet and hands for warmth,color,or edema. Encourage resident to be out of bed daily and exercise. Medications as ordered
. Notify MD if edema or shortness of breath occurs. Lab and Xray as ordered Monitor for and be present to render support to prevent anxiety if episode of SOB occurs. Encourage resident to attend activities which don't depend on
major physical stamina or exertion: Have O2 available if needed. Diet as ordered.
Monitor for congestion or elevated temperature and notify MD promptly if they occur. Encourage fluids.Monitor resident for episodes of SOB and impllement interventions as ordered.Monitor feet and hands for warnth,color,or ed
ema. Encourage residents to be out of bed daily and exercise.Medications as ordered.Lab and Xray as ordered.Have O2 avilable if needed.Diet as ordered. Encourage resident to attend activities which don't depend on
major physical stamina or exertion:Music, movies,word games.
When resident is upset,staff to try to alter residents environment take to activities,on walk. Encourage resident to be involved in activities. Listen attentively and attempt to resolve or discuss area of upset.
Monitor weight,appetitie,labs,environment,medications to assist physician in finding clinical cause. Notify MD if it interferes with functioning.
BEHAVIOR MODIFICATION PLAN: Always approach resident calmly and unhurriedly.Speak in a calm voice. Encourage resident to perform independent ADL's and decisions concerning timing of c
are,clothes to wear, what activities to attend. Listen attentively. Attempt to refocus behavior to something positive when resident is depressed. Encourage and assist resident to help staff in mutual problem solving of depression causing s
timuli.Encourage activities of resident's choive and preference:
BEHAVIOR MODIFICATION PLAN: Monitor for hyper or hypo activity levels. When resident is upset,staff to try to alter residents environment take to activities,on walk. Encourage resident to be involve
d in activities. Listen attentively and attempt to resolve or discuss areas of upset.Monitor weight,medications,appetite, labs,enivironment,medications to assist physician in finding clinical cause. Notify MD
if it interferes with functioning.
Keep environment free of small objects on floor,very hot liquids,and toxic liquids. Involve in Auditory activities:music,parties,exercise. Vision screening if ordered and indicated. Explain location of food on tray
if needed. Announce self when entering residents area. Special precautions in emergencies. Encourage independence in ADL's. Reorient residents if furniture is moved or change in environme
nt.Monitor for vision problems.
Monitor for eye pain or decrease in vision and report to MD.Eye gtts. if ordered. Keep environmenmt free of small objects on floor,very hot liquids,and toxic liquids.Involve in Auditory activities,music,parties,exercis
e.Vision screening if ordered and indicated. Explain location of food on tray if needed. Announce self when entering residents area.Special precautions in emergencies.Encourage independence in ADL's.
MOnitor output for blood and report to MD promptly. Dietary to assess for diet needs. Encourage 80-100% of diet. Lab as ordered-report abnormals promptly. Medications asa ordered.
Monitor for GI distress.
Position of comfort. Range of motion to comfort. Medication as ordered. Monitor for GI distress. Encourage activity attendance an
d exercise to keep busy. Rest after medication to facilitate relief.
Monitor for weakness or tireness and encourage naps as needed. Medication and lab work as ordered-report abnormal results promptly. Encourage Activities of choice:
Report excessive weakness,pain weight loss,sadness,poor appetitie, or tiredness to MD. Encourage 80-100% of diet. Monitor weights and appetitie. Permit resident to verbalize
feelings and concerns over disease and attempt to resolve concerns.
Diet as ordered.Monitor intake. Medication and lab as ordered. Report abnormal results promptly. Monitor for thirst,excessive appetite or voiding, change in level of consciousness
or mood,perspiring and report to MD promptly. Special monitoring of skin for redness or circulatory, problems.Monitor and assure position changes. Encourage exercise and activity attendance.
Monitor for complaints of pain or discomfort and do interventions as ordered. Encourage vistors. Monitor for abnormal weight loss,appetite,skin breakdown,and lab and report to
MD promptly. Encourage socialization and activity daily. Listen to resident and resolve concerns as possible.
Monitor for complaints of pain or discomfort and do interventions as ordered. Encourage socialization and activities daily. Listen to resident and resolve concerns as possible. Adhere to no CPR request.
Monitor for weakness or tiredness and encourage naps as needed. Medication and lab work as ordered- report abnormal results promptly. Encourage activities of choice:
Report excessive weakness or tired to Md. Encourage 80-100% of diet. Monitor weights and appetite.
Handle gently when moving resident. Encourage 80-100% of diet. Encourage resident to do mild exercise. Report any pain,redness, or swelling promptly.
Xrays as ordered with abnormal results reported promptly. Medications as ordered.
Medication and lab work as ordered-report abnormal labs to MD promptly. Monitor side rails and positioning for possible injuries. Report all seizures to MD promptly. monitor for changes in level of
consciousness. Monitor for nausea and vomiting and report to MD promptly. Protected environment when having a seizure. Monitor weights and appetite.
Give medication as ordered. Lab or xray as ordered with abnormals reported promptly to MD. Encourage fluids. Monitor temperature Q shift. and report if medication is inef
fective. Cooling measures if fever occurs.
Medications as ordered. Monitor urine for sediment,cloudy,odor,blood,amount. Report abnormals to MD promptly. Monitor temperature and report fever promptly to MD. Encourage fluids.
Lab work as ordered with abnormals results reported to MD promptly.
Reality orientation while giving care. Involve in enjoyable activities which orient to reality and don't depend on orientation. Encourage family to visit and bring photos and mementos.Keep environment free o
f hazards. Pleasant interaction which reassures resident when confused. Explain all procedures. Encourage reminiscence and small group interaction. Assist in emergencies.Verbal reminders which assist resident in orientati
on.Post activity schedule.
Encourage 80-100% of diet. Monitor BM's for amount and consistency and give laxatives as ordered and needed. MOnitor medications for cause of constipation. Encourage resident to drink flui
ds. Encourage resident to get out of bed daily and get exercise. Medications as ordered.
Position of comfort. Medications as ordered-notify MD if ineffective. Monitor environment for wet spots or items placed below field of vision floor. Assure that lighting is adequate.Monitor for side eff
ects from medications,labs,appetitie as cause for falls. Calll light close and answered promptly. Monitor resident for steadiness and balance. Instruct resident not to have suddent position changes.
Monitor for muscle weakness, hypotension,muscle spasms. Lab as ordered and report low K levels promptly. Monitor dietary intake-dietician to evaluate diet for potassium content. Medications as ordered-monitor f
or nausea. Encourage 80-100% of dietary intake.
Quiet environment. Encourage resident to stay up during day for sleep at night. Monitor causes for insomnia,medications,over stimulation,depression,anxiety.
Medicztion as ordered and needed. Encourage activity attendance during day.
Diet and medications as ordered. Lab as ordered with abnormals reported to MD promptly. Monitor for nausea, vomiting, G.I distress, or ascites and reort to MD promptyly.
Monitor resident for episodes of shortness of breath and implement interventions as ordered. Monitor feet and hands for warmth,color,or edema. Encourage resident to be out of bed daily and exercise. Medications as ordered
. Notify MD if edema or shortness of breath occurs. Lab and xray as ordered. Monitor for and be present to render support to prevent anxiety if episode of shortness of breath occurs. Encourage resident to attend activities which don't dep
end on major physical stamina or exertion. Have 02 available if needed.Diet as ordered.
Monitor feet and hands for edema. Encourage resident to be out of bed daily and exercise. Diet and medications as ordered. Notify MD if edema,chest pains,elevated B/P or shortness of breath occurs. Lab and xray as o
rdered. Good personal hygiene. Notify MD if resident complains of itching. Monitor urine output.
Monitor for complaints of pain or discomfort and do interventions as ordered. Encourage socialization and activity daily. Listen to resident and resolve concerns as possible. Adhere to no CPR request.
Diet as ordered. Meds as ordered. Monitor appetite,weight, and relief from medication- notify MD if medication is ineffective.
Give medication as ordered monitor for abnormals labs and nausea. Lab or Xray as ordered with abnormals reported promptly to MD. Encourage fluids. Monitor temperature Q shift and report if medication is ineffective. Cooling measures
if needed. Monitor appetite. Contact isolation -practice good infection control. Room visits and activities daily. Cheerful dialogue while giving care. Treatments as ordered - notify MD if ineffective.
Reality orientation while giving care. Involve in enjoyable activities which orient to reality and don't depend on orientation. Encourage family to visit and bring in photos and mementos. Keep environment free
of hazards. Pleasant interaction which reasssures resident when confused. Explain all procedures. Encourage reminiscence and small group interaction. Assist in emergencies. Verbal reminders which assist resident in orient
ation. Post activity schedule. Monitor Dietary intake and weights.
Have call light close and answer promptly. Instruct resident to ask for assistance if dizzy or weak. Monitor medicationa, lab and diet for potential causes of dizziness. Respect residents rights to inde
pendence. Monitor residentfor steadiness. Discourage resident from abrupt position changes.
Give medications as ordered monitor for abnormal labs and nausea.Lab or Xray as ordered with abnormals reported promptly to MD. Encourage fluids. Monitor temperature Q shift and report if medication is ineffective. Cooling measures
if needed. Monitor appetite. Contact isolation -practice good infection control. Room visits and activities daily. Cheerful dialogue while giving care. Treatment
as ordered-notify MD if ineffective.
Reality Orientation while giving care. Involve resident in enjoyable activities which orient to reality and don't depend on orientation. Encourage family to visit and bring photos and mementos....Keep environment fre
e of hazards.Pleasant interaction which reassures resident when confused. Explain all procedures. Encourage reminiscence and small group interaction. Assist in emergencies. Give verbal reminders which assist resident in orientation. Post Acti
vity schedule.Monitor Dietary intake and wts.
Monitor feet and hands for edema. Encourage resident to be out of bed daily and exercise.Diet and medications as ordered. Notify MD if edema,chest pains,elevated B/P or shortness of breath occurs. Lab
and xray as ordered. Good personal hygiene. Notif MD if resident complains of itching. Monitor urine output.
Monitor for complaints of pain or discomfort and do interventions as ordered. Enocurage socialization and activity daily. Listen to resident and resolve concerns as possible. Adhere to no CPR request and pol
Diet as ordered. Meds as ordered. Monitor appetite,weights,and relief from medication. Notify MD if medication is ineffective.
Encourage 80-100% of diet. Monitor BM's for amount and consistency and give and give laxatives as ordered and needed. Monitor medications for cause of constipation. Encourage resident to drink flui
ds. Encourage resident to get out of bed daily and get exercise. Medications as ordered.
Medicatin as ordered. If diarrhea persists,have dietician evaluate diet. Encourage fluids. Monitor skin formbreakdown. Lab as ordered.
Report to MD if diarrhea not relieved by medication. Monitor medications,appetite,lab,for possible causes.
Have call light close and answer promptly. Instruct esident to ask for assistance if dizzy or weak. Encourage fluids. Monitor medications,fluid intake,lab and diet for potential causes of dizziness. Respect residents right to indep
endence. Monitor resident for steadiness. Discourage resident from abrupt position changes.
Monitor feet and hands for edema and monitor for S.O.B Encourage resident to be out of bed daily and exercise. Medications as ordered. Notify MD if edema occurs.
Monitor skin for red areas. Lab as ordered.
Encourage 80-100% of diet. Monitor BM's for consistency and amount and give laxatives or enemas as ordered or needed. Monitor diet and medications for cause of constipation.
Encourage resident to drink fluids. Encourage resident to get out of bed daily and get exercise.
Give memdications as ordered. Lab or xray as ordered with abnormals reported promptly to MD. Encourage fluids. Monitor temperature Q shift and
report if medication is ineffective. Cooling measures.
BEHAVIOR INTERVENTIONS: Always approach resident calmly and unhrriedly. Speak in a calm voice. Encourage resident to peform independent ADL's and decisions concerning timing of c
are,clothes to wear, what activites to attend. Listen attentively. Attempt to refocus behavior to something positive when resident is delusional. Encourage
and assist resident to help staff in mutal problem solving of causing stimuli.
Monitor output for blood. Monitor pain,appetite,medications,lab to assist MD in determining cause. Medication as ordered. Lab as ordered.
Encourage 80-100% of diet and fluids on tray. Monitor V.S if active bleeding suspected.
Position of comfort. Range of motion to comfort. Medication as ordered. Monitor for GI distress. Encourage activity attendance an
d exercise to keep busy. Rest after medication to facilitate relief.
Position of comfort . Range of motion to comfort. Medication as ordered. Monitor for GI distress,weakness,unstable balance. Encourage activity attendance to
keep busy. Rest after medication to facilitate refief.
Monitor for tolerance of feeding and report diarrhea or vomiting. Head up during feeding. Diet as ordered with monitoring for texture tolerance. Report any choking,coughing,vomi
tinig to MD promptly.
Monitor resident for eposodes of shortness of breath and implement interventions as ordered. Monitor feet and hands for warmth,color,or edema. Encourage resident to be out of bed daily and exercise.Medications as ordered.
Notify MD if edema or shortness of brreath occurs. Lab and xray as ordered. Monitor for and be present to render support to prevent anxiety if episode of shortness of breath occurs.En
courage resident to attentd activity which don't depend on major physical stamina or exertion.
Have call light close and answer promptly. Instruct resident to ask for assistance if dizzy or weak. Encourage fluids. Monitor medications,fluid intake, lab and diet for potential causes of dizziness.
Respect resident rights to independence. Monitor resident for steadiness. Discourage resident from abrupt position changes.
Monitor and encourage fluids and notify MD if inadequate fluids taken. Staff to encourage intake each shift. Lab and medications as ordered with abnormals reported promptly.
Notify MD if vomiting persists. Staff to monitor medications, diet, environment, and labs for possible causes.
Monitor environment for wet spots or items placed below field of vision on floor. Assure that lighting is adequate. Monitor for side effects from medications,labs,appetite as cau
se for falls. Call light close and answered promptly. Monitor resident for steadiness and balance. Instruct resident not to have sudden position changes.
Assist MD in determining why functioning has been lost. Assess for rehabilitation. Monitor medications,appetite,labs,weights,ability to move,level of consciousness and report any abnormals to MD promptly.
Monitor for complaints of pain or discomfort and do intereventions as ordered. Encourage visitors. Monitor for abnormals weight loss, appetite , skin breakdown, and lab results and r
eport to MD promptly. Encourage socialization and activity daily. Listen to resident and resolve concerns as possible.
Dental consult as needed or ordered. Treatment as ordered. Monitor and rreport to MD if not improved. Monitor meals to assure appropriate texture. Mouth care as tolerated.
Encourage 80-100% of diet intake. Nourishments as ordered assist as needed with meals. Adhere to food preferences. Monitor lab,appetite, and medications for possible side effects. !
Monitor weights and report continued loss to MD promptly. Give enough time to eat. Asses location of meals for possible change in location. Monitor a
nd encourage fluid intake,skin turgor,dry mouth.
Adhere to food preferences. Monitor and discuss complaints with residnet and decide together what food they would like. Monitor weights and report + or -5 pounds to MD. Monitor for good oral hygiene.
Monitor medications and labs for possible causes.
Encourage and monitor fluid intake. Monitor skin turgor and for leg cramps. Lab and medications as ordered. Monitor lab and medications for possible causes.
Encourage and monitor fluid intake. Monitor skin turgor and for leg cramps. Lab and medications as ordered. Monitor lab and medications for possible causes.
Dietary to visit and plan meals and snacks according to residents requests and physicians orders. Offers snacks that are within diet. Monitor weights. Monitor at meals times to assess
eating pattern.
Dieatary to adhere to food preferences. Dietary to send in between meal snacks which are within diet. Monitor weight and report five pound losses to MD. Assure good oral hygiene.
Monitor labs and medications for possible causes. Monitor skin turgor.
Intake and Output : At least ____________cc per day. Notify MD if inadequate fluids taken. Staff to encourage intake each shift. Lab and medications as ordered.
Monitor IV site for redness or swelling. Change dressing and IV as ordered. Monitor for good skin turgor.
Monitor for tolerance of feeding and report diarrhea or vomiting. Change tube and tubing as ordered. Check tube for placement at least every shift. Monitor lab and weights as ordered. Report loss or abnormals promptly. .
Good oral hygiene. Feeding as ordered.OOB daily as tolerated and to activities as tolerated.Socialization visits if stays in bed or room. Keep head
elevated during feedings. Monitor for possible feeding retraining.
Diet as ordered. Encourage resident to eat 80-100% of meal. Adhere to food preferences. Dental consult if indicated. Monitor for appetite,weight loss
, and texture tolerance.
Diet as ordered. Encourage resident to eat 80-100% of meal. Adhere to food preferences. Dental consult if indicated. Monitor for choking.
Monitor weights and appetite. Head elevated when feeding. Monitor for possible feeding retraining.
Diet as ordered. Encourage food preferences within diet. Monitor weights and report five
pound loss to mD. Monitor lab as ordered.
Encourage 80-100% of diet and nourishments as ordered assist as needed with meals. Adhere to food preferences. Monitor lab,appetite,and medications for possible side effects.
Monitor weights and report continues loss to MD promptly. Give enough time to eat. Assess location of meals for possible change in location.
Assess ability to eat and provide adaptive equipment. Praise when independent. Monitor weeight loss.
Provide diet as ordered by MD. Monitor weight Qmonth. Report to MD wt loss/gain of 5 p:
ounds. Monitor food consumption. Disourage between meal snacks. Praise wh
en weight is lost.
Provide diet as ordered by MD. Monitor weight q month. Report to mD wt loss/gain of 5 lbs. Encourage intake of 80-1--% of meals.. Encourage between meal snacks.
Adhere to food preferences. Monitor lab,appetite,environment,and medications for possible causes for low weight.
Staff to encourage oral hygiene before bed at night and PRN with asistance as needed.
Diet as ordered. Monitor tolerance of texture of food. Monitor appettite and weights an
d report weight loss of 5+ pounds. Dental consult as ordered and needed.
Diet as ordered. Monitor tolerance of texture of food. Monitor weights and report weight loss of 5+ pounds. Dental consult and follow-up as ordererd and needed.
Dental consulation as ordered. Treatment as ordered. Monitor for pain and notify MD. Give good oral hygiene. Monitor for tolerance of diet.
Use swabettes to keep gums clean. Encourage 80-100% of dietary intake. Monitor weights and notify MD if
loss of 5 or more pounds. Dental consult if ordered and needed. Monitor for tolerance of food texture.
Turn and reposition with devices at least every two hours. Keep clean and dry. Treatment as ordered-notify MD if treatment ineffective. Good infection contF
rol when dealing with ulcer. Report any drainage to MD. Encourage 80-100% of diet as odered. Pressure relieving mattress. Dietary to assess diet,vitamins,and mineral supplements. Lab as or
ders.OOB daily to tolerance. ROM by staff giving care. Monitor for circulatory
Turn and reposition with devices at least every two hours. Keep clean and dry. Treatment as ordered- notify MD if treatment ineffective. Good infection controll when dealing with ulcer. Report any drainage to MD. I
Encourage 80-100% of diet as ordered. Pressure relieving mattress.Dietary to assess diet for protein,calories,vitamins,and mineral supplements. Lab as ordered.OOB daily to tolerance. ROM by st
aff giving care. Monitor for circulatory.
Turn and reposition with devices at least every two hours. Keep clean and dry. Encourage 80-100% of diet as ordered. Pressure relieving mattress. Dietary to asses diet,vitamins,a
nd mineral supplements. Lab as ordered. OOB daily to tolerance. ROM by staff giving care.
Turn and reposition with devices at least every two hours. Keep clean and dry. Encourage 80-100% of diet as ordered. Pressure relieving mattress. Dietary to assess diet,vitamins,N
and mineral supplements. Lab as ordered. OOB daily to tolerance. ROM by staff giving care. Monitor for need for padding to side rails or wheel chairs. Monitor for discoloration, bruises,s
welling,skin tears, redness and report promptly.Special attention when moving resident.
Turn and reposition with devices at least every two hours. Keep clean and dry. Encourage 80-100% of diet as ordered. Pressure relieving mattress. Lab as ordered. Dietary to assess diet,vitamins Q
,and mineral supplements. OOB daily to tolerance. ROM by staff giving care. Monitor for need for padding to side rails or wheel chairs. Monitor for discoloration, bruises,swelling,skin tears,red
ness and report promptly.Special attention when moving resident.
Turn and reposition with devices at least every two hours. Keep clean and dry. Encourage 80-100% of diet as odered. Pressure relieving mattress. Dietary to assess diet,vitamins
and mineral supplements. Lab as ordered. OOB daily to tolerance. ROM by staff giving care.
Turn and reposition with devices at least every two hours. Keep clean and dry. Encourage 80-100% of diet as ordered. Pressure relieving mattress. Dietary to assess diet,vitamins,
and mineral supplements. Lab as ordered. OOB daily to tolerance. ROM by staff giving care.
Turn and reposition with devices at least every two hours. Keep clean and dry. Encourage 80-100% of diet as ordered. Pressure relieving mattress. Dietary to assess diet, vitamins
, and mineral supplements. Lab as ordered. OOB daily to tolerance. ROM by staff giving care.
Keep clrean and dry. Treatment as ordered:notify MD if treatment ineffective. Good infection control when dealing with wound. Repodrt any drainage to MD.
Encourage 80-100% of diet as ordered. Monitor dietary intake. Lab as ordered.
Tuen and reposition with devices at least every two hours. Keep clean and dry. Encourage 80-100% of diet as ordered. Pressure relieving mattress. Dietary to assess diet,vitamins \
and mineral supplements. Lab as ordered. OOB daily to tolerance. ROM by staff giving care. Monitor for need for padding to side rails or wheel chairs.Monitor for discolora
tion,bruises,swelling,skin tears,redness and report promptly.Special attention when moving resident.
Medication as ordered. Lab as ordered. Monitor for blood in urine or stool. Monitor for bruising or bleeding.
Encourage rest after chemotheraphy. Lab and medications as orderedd with abnormals reported promptly. Notify MD if vomiting persists. Staff to monitor medications,diet,environment,and labs for possible causes. `
Encourage fluids as tolerated. Medication if ordered-report to MD if ineffective. Visit with resident when sick to help relieve anxiety due to vomiting. Monitor d
iet for tolerance.
Medications as ordered. Monitor pulse daily and report if abnormal. Lab work if ordered with abnormals reported promptly to MD. MOnitor for chest pains or abnormal pulses and report to MD.
Monitor for 6-8 hours of sleep. Monitor for nausea or vomiting.
Will not have any side effects from medication. No falls. Monitor for side effects and report to MD. Side Effects: --------------------------- Common: Hypotension,bradycardia,e
light headedness,nausea,fatigue,weakkness,skin rash,fever,sore throat,swelling of extremities.Special concerns:Contraindicated in asthmatics,bronchospasm, and COPD. Avoid abrupt discontinuation. Pharmacis
t to review drug regime monthly. Labs as ordered with abnormals reported promptly.
Monitor for side effects and report to MD promptly. Side Effects: ------------------ Common: Nausea,vomitng,diarrhea,muscle weakness,fine hand tremors,thirst,polyuria,dehh
ydration,sluggish dazed feeling,drowsiness. Asses daily for behaviors mannifested and notify MD if medication can be reduced. Monitor for unsteady balance. Pharmacis
t to review drug regime monthly. See behavior Interventions plan.
Monitor for side effects and report to MD promptly: Side Effects ----------------- Common:drowsiness,lethargy,dizziness,loss of coordination,ataxia,sore throat,
fever,easy brusing and bleeding. Special concern:aplastic anemia, agranulocytosis,glaucoma.Lab monitor CBC. Asses daily for behaviors manifested and notify MD if medication can be reduced.
Medications as ordered. Monitor for mood swings or infection and report to MD promptly. Good infection control when deal
ing with resident. Lab as ordered with abnormals reported promptly.
Encourage rest after chemotherapy. Lab and medications as ordered with abnormals reported promptly. Notify MD if vomiting persists. Staff to monitor medications,dieo
t,environment,and labs for possible causes. Medication if ordered-report to mD if ineffective. Visit with residnet when sick to help relieve anxiety due vomitng. Monitor d
iet for tolerance.
Encourage rest after radiation. Lab and medications as ordered with abnormals reported promptly. Notify MD if vomiting persists. Monitor skin. STaff to monitor medications,diet, environment,and labs for possibl
e causes. Medication if ordered -report to MD if ineffective.
Monitor feet and hands for edema. Encourage residnet to be out of bed and exercise. Diet and medications as ordered. Notify MD if edema,chest pains,elevatede B/P or shortness of breath,bleeding occt
urs. Lab and xray as ordered. Do Not Take B/P in :___________arm. Good personal hygiene. Arrange for dialysis as ordered. Monitor o
utput for blood.Encourage socialization and activity attendance.
Monitor for congestion and suction when needed. Encourage residnet to be out of bed daily. Monitor resident for episodes of shortness of breath and implement intervention as ordered. Medications as ordered. w
Notify MD if edema or sob is not relieved by interventions. Lab and xray as ordered. Encourage residnet to attend activities which don't depend on major physical stamina or exertion:Music, games,par
ties.Monitor for elevated temperature.
Monitor for congestion and suction when needed. Tracheostomy care as ordered. Monitor for infection. Encourage residnet to be out of bed daily. Monitor resident for episodes ofz
shortness of breath and impllement interventions as ordered. Medications as ordered. Lab and xray as ordered. Have O2 available if needed. Monitor a
nd report elevated temperature and report to MD promptly.
Medications as ordered. Monitor vital signs. Intake and Output: at least ________ cc per day. Staff to encourage intake each shift. Lab and medications as ordered.
Monitor IV site for redness or swelling. Change dressing and IV as ordered. Monitor for good skin turgor.
Monitor for fever, abnormal pulse or B/P, loss of appetite, change in level of consciousness,skin rashes or eruptions and report to MD promptly. Good infection control. Monitor needlesite for redness,p
ain,or swelling. Lab as ordered with abnormals reported promptly.
Monitor resident for episodes of shortness of breath and implement interventions as ordered. Monitor feet and hands for warmth,color,or edema. Encourage resident to be out of bed daily and exercise. Medications as ordered
. Monitor for and be present to render support to prevent anxiety if episodes of shortness of breath occurs. Diet as ordered. Lab as or
dered. Have O2 available if needed.
Pacemaker check as ordered. Notify MD if pulse below 60 and/or resident becomes symptomatic:SOB,chest pain, dizziness,altered LOC, hypotension. Keep resident away from runing m
icrowaves.
Bed rails to prevent injury from falling out of bed. Reposition at least every two hours. Release and monitor if resident becomes agitated. Evaluate at least every three months for less restrictive measures.
Visual check at least every two hours for positioning and circulatory problems. Continued exercise to prevent decreased functioning.
__________________________Restraint when:_______to prevent injury from: ____________________________________Release and reposition at least every two hours. Release and monitor if resident
becomes agitated. Encourage activity attendance. Evaluate at least every three months for less restrictive measures. Monitor for effectiveness or need for continued use. Visual ch
eck at least every two hours for positioning and circulatory problems.
Mitten to:_____________________________________________ when: ______________________________________to prevent injury to self from: ________________________________
_________________ __________________________________________Release and give ROM to hand at least every two hours. Monitor for placement of tube. Release and monitor if resident becomes agitated. Encourage
activity attendance. Exercise to prevent decreased functioning.
_____________________Release and reposition at least every two hours.Release and monitor if resident becomes agitated. Encourage activity attendance. Evaluate
at least every three months for less restrictive measures.
Monitor for side effects and report to MD promptly. Assess daily for behaviors manifested and notify MD if medication can be reduced. Monitor weights and appetite. Monitor forunsteady balance.Phar
macist to review drug regime monthly. Call light available. Resident to ask for assistance when unsteady. Monitor behaviors and report monthly to MD to assist to assure lowest possible therapeutic doses given.
Asses daily for behaviors manifested and notify MD if medication can be reduced. Monitor appetite and weights. Monitor for unsteady balance. Pharmacist to review drug regime
monthly. Call light available. Resident to ask for assistance when unsteady. Monitor behavior and report monthly to MD to assist to assure lowest possible therapeutic doses given.
Assess daily for behaviors manifested and notify MD if medications can be reduced. Monitor weights and appetite. Monitor for unstready balance. Pharmacist to review drug regime
monthly. Call light available. Resident to ask for assistance when unsteady. Monitor behaviors and report monthly to MD to assist to assure lowest possible thrapeutic doses given.
Medications as ordered monitor. Lab work if ordered with abnormals reported promptly to MD. Encourage 80-100% of diet.
Encourage activity and mild exercise daily. Monitor for chest pains or abnormal pulses and report to MD. Monitor for 6-8 hours of sleep. Encourage
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