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Pocket Care Plan                                                   

Room#

 

Resident

Name

Nutrition

Needs

Bowel/

Bladder

Transfer / Mobility

SAFETY

*Fall Devices

*Smoking

*Elopement

Cognition/ Behavior

Sensory

Devices/

Dentures

Skin Care/

Pressure Ulcer

Comments/

Special Instructions

 

10

 

 

NAS

Set-up

Before Meals and 3pm/3am

Med briefs

2 assist stand pivot GB w/c

Fall risk

Bed low

2 mats

Green gripper pad in wheelchair

Alert and confused

Glasses

R hearing aide

T+P splint to left hand at HS

Ask about fishing in Canada

Has 35 Grandchildren

 

12

 

 

NAS

Set up

lg brief

Rt arm sling

R arm hemi walker

Fall risk               Bed lowest position

Alert, confused at times

Glasses      Hears best in R ear    

Keri oil in wash basin/see RCR

Allow ample time to respond/aphasia;

 

13

 

 

NAS/CATNCS Unit set up

Med briefs

2 Mech lift broda

Fall risk chair and bed alarm  bed low    

Alert confused Behavioral

Dentures

upper

Zincon shampoo

When combative reapproach later for ADLS. Floor mate on Lside bed.

 

14

 

 

NCS, NAS  unit

Ground honey thick

XX LG. briefs

2stand up lift w/c

Bed low position

Alert

Reading glasses

denture

Lotion to dry skin see RCR

Dressed , shaved, ready to go out on Sundays

 

15

 

 

NAS CAT

Med briefs pull-ups

Indep in Rm with RW w/c

 

Alert

Oriented

Glasses partial denture

T+P elevate legs

O2 at 4-5L continuous

Provide rest periods for SOB

 

16

 

 

Reg. CAT

No caffeine

Large brief

2Mech.lift

broda

Fall risk

Bed low

1 mat

Alert

Oriented

Glasses

Dentures

T+P lotion to dry skin

See RCR

 

 

17D

 

 

Reg. CAT

Med.

brief

2 Assist with GB w/c

Fall risk

Bed low

2 mats

Alert

Confused

Dentures

T+P

See RCR

Do not leave unattended in bathroom

 

17W

 

 

Low fat &

Cholesterol

2Gm NA

insert

Self with

Rolling walker

 

Alert

Oriented

Confused

Glasses

Good peri care

 

 

18

 

 

NCS, NAS

RDR with

set up, assist

X-large

brief

1 Assist

RW &  GB w/c

Bed low  chair alarm

Alert

Oriented

Confused

Behavior

Glasses

Dentures

 

Electric razor only. When combative leave alone and report to charge nurse. Reproach  later

 

19D

 

 

Reg. CAT

Pull-ups

Med.

2 Assist GB w/c

Bed low

Floor mat

Chair alarm

Alert

Confused

Glasses

Lotion to legs and feet

See RCR

Not leave unattended

In bathroom. See RCR

 

19W

 

NAS CAT

Pull-ups

Large

2 Assist with RW & GB w/c

Bed low

Alert

 Oriented

Glasses

Skin barrier as needed

R arm Hx of rotator cuff injury

 

20

 

 

NCS, NAS

CAT

Pull-ups day

Large brief night

1 Assist with RW & gait belt w/c

Bed low

Alert

Confused at times

Glasses

 

 

Lay down in bed 20 min. every morning after breakfast to relieve pressure on buttocks

 

21

 

Regular

Med.

Brief

1 Assist GB w/c

Bed low

Alert

Oriented

Glasses

Lotion to dry skin  see RCR

Hx of seizures may report to staff  of signs of seizures See RCR

 

31

 

 

NCS, NAS,CAT Rose room

Large briefs

2 Mech. Lift w/c

Fall risk, chair and bed alarm Bed low position, floor mat

Alert

Disoriented behavioral Wander Risk

Glasses

Lotion to dry skin

At risk for elopement

 

32

 

 

Regular CAT Nectar thick

Med brief foley cath,

2 mech. lift

Hx of falls, bed in lowest position

Alert, conf

 

TP schedule, lotion to dry skin

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