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Care planning prompt notes.pptx
- 1.
- 2. Communication Do they communicate verbally? Istheir eye sigh satisfactory? Do they wear glasses? Who is their chosen opticians? Is there hearing satisfactory? Do they wear aids? Do they need support in changing batteries and putting aids in? Do they often suffer with blocked ear and benefit from olive oil drops? Body language, What may they typically display through there body language when they are unhappy/happy. Telephone ? Do they have access to a telephone within there bedroom or a mobile. Do they need a specialist telephone with large numbers to see ? Do they need assistance with dialling numbers. Are they able to communicate when they are in pain? VRS pain score need to be used or abbey pain score to be used? How do they communicate anxiety/frustration? Communicating with others? Do they enjoy engaging with others? How are we as a home communicating events/ activities and news updates? News boards, activity planners, Home’s news papers. Can they use the bell? How do they summon assistance?
- 3. Continence Linked assessments: Continence (mandatory) EtonConstipation (is applicable)
- 4. Continence Are they continent?Are they doubly incontinent? Personal care needed. Do they need continent aids? Are they being prescribed and does a assessment need to be carried out to have them prescribed? Or do they wish to purchase their own? What support level is needed when using the toilet? Link skin integrity to the care plan? Do they need any aids when using the toilet? Toilet raiser? Commode? Do they suffer with constipation? What plan is in place to support this? Stoma Care. & Catheter care. Can the communicate to you if they need to use the toilet? Have they made a preference of female and male carers?
- 5. Daily life/ Lifestyle Linkedassessments: Barthel (mandatory) Dependency (mandatory) Please add a Visits Care Plan
- 6. Daily life/ life style Dothey have any specific routines that they like to follow during the day and night? Have they made any known wishes regarding there care? Such as being disturbed before 8am. What activities/interests and hobbies do/did they have? What do we do to meet these needs Dining preferences. Life history. Do they like newspapers, reading materials or audios? Do they prefer to socialise with others or prefer there own company? What do they do in a normal day? Do they preferer to spend more time out in the gardens or community than indoors?
- 7. Death and Dying LinkAssessments: • Advanced Care Plan
- 8. Death & Dying. Dothey have a RESPECT form in place? DNAR. If they are stable Do they wish to discuss their death and dying wishes? And if so what are they? Have they chosen or pre arranged a funeral director? If they would like a particular family member or friend to be kept updated with regards to there health who would this be? Have family and friends made any wishes in regards to be informed whether its day or night. Are they on a syringe driver? Are they receiving palliative care and what is their prognosis? Are there any written statements of wishes made by the person?
- 9. Emotional Support Linked Assessments: CornellDepression Scale (if applicable) Crichton scale (if applicable) Behaviour Development (if applicable)
- 10. Emotional support. Do they havea cognitive diagnosis that could effect their emotional well being? Environments? Is there a preferred environment, do they find loud environments overwhelming? Who do they seek emotional support from? Family, care team friends? When might they need emotional support? Do they have any support from the MHT? Is there anything relating to there life history that can effect their emotional well- being? Do they experience upset/distressed behaviour? How can we support them with this? Do they know where they are? Do they accept being in a care home?
- 11. Finance. Does the personhave capacity to make all decisions relating to there finances? Does the person have a chosen Lasting power of attorney for financial & property affairs? Does the resident keep their own money on them or is there money kept within the safe in the admin office for use of small purchase’s? Care funding. Are they self funding? Or receiving financials support?
- 12. Maintaining Safe Environment LinkedAssessments: Falls Risk (mandatory) PEEP (mandatory) General risk (if applicable) Safe smoking (if applicable) Bed rails (if applicable and unable to consent) MCA – sensor mat (if unable to consent) MCA – bed rails (if unable to conset)
- 13. Maintaining a safe environment. DOLS inplace? Refer to the DOLS if they are restricted from leaving the building alone? PEEP in place and where this can be located to use in the event of an evacuation. Are they presenting as a risk of falls? Are they able to perceive hazards? Can they call for help? Do they need glasses? Detail that we need to prompt people to wear to aid eyesight. Are they mobile?- link to mobility care plan? Any known allergies? Detail the risk of slips trips and fall removing all potential hazards from their environment. Are they able to regulate temperatures ? Accordingly and need support?
- 14. Medical Add a separatecare plan for: CVA Parkinson’s MS Diabetes Epilepsy Wounds Please add a Covid-19 Care Plan
- 15. Medical Do we havea medical summary and link this to the care plan. Do they have a treatment escalation plan in place DNAR.? What is there known medical diagnosis? Any known medical allergies? Does the persona have a chosen lasting power of attorney for health & welfare? Does the person wish for us to update family/friends in regards to any changes within there medical health? Is the person self medicating or needing support? Covert medication? Registered GP? Are they able to hold review meetings with the GP themselves or would they like support in arranging this. Do they need there blood sugars, INR, blood pressures taken on a regular basis?
- 16. Medication Linked Assessments: Self Medication(Mandatory) MCA - Administration of medication (if unable to consent) MCA – Covert Medication (if applicable)
- 17. Medication Are they self administeringtheir own medication or need support? Please complete a self-med assessment. Can they consent to the administration of meds? Please state or MCA Covert medication? LPA over health & welfare, inform and update as the resident wishes us too. Do they have any difficulty with taking medication and do they have a preferred way in taking this? Are they on any time critical medication, what is this and reference to the Emar. Is there any known medication allergies? Reference to the Emar, FP10 homely remedies and PRN protocols in place and where these can be located. Is the person taking any medication where they pulse rate will need to be measured before hand? Or there INR to be tested rguarly. Is the person on any antipsychotic medication? Due to be reviewed six weekly.
- 18. Mental Capacity Linked assessments: AnyMental Capacity Assessment Please add a DoLS care plan if there is a DoLS application
- 19. Mental capacity Have theygot capacity? Has a DOLS been applied for ? When was it applied for – link to DOLS care plan. Have they got a appointed person for Lasting power of attorney for both financial affairs and health and welfare. Are they able to contribute in making decisions relating to their care and finical matters? Link in any consent forms that have been signed by the person or there LPA on their behalf. Are they able to be involved in small decisions
- 20. Mobility Linked Assessments: Falls Risk(mandatory) Mobility (mandatory)
- 21. Mobility Are they mobileor need assistance with transferring? What aids do they need to support them? Are they receiving any support from the Physio or OT? Can their motility be effected if they are unwell? Do they have suitable footwear? Do they have bed rails in place? Is there any health issue that will effect their mobility long term ? Are they at risk of falling? Link in falls assessment with clear guidance of how we are supporting this risk to be reducecd.
- 22. Nutrition Linked Assessments: Nutrition (mandatory) MUST(mandatory) Chocking (mandatory) Fluid Watch (if applicable)
- 23. Nutrition Have they gotany dietary likes/dislikes? Any known food allergies? Any dietary intolerances? Any specialist diet? Are they on a specific food or fluid texture? Link in MUST assessment, are they on weekly or monthly weights? Do they have any adapted cutlery or crockery? Do they need support with eating and drinking? Are they under weight and need the support of any supplements? Or already under the care of the detain? Are they at risk of dehydration? If so also create a general risk assessment and link it to this care plan. Where do they prefer to eat? Lounge/bedroom
- 24. Personal Care Linked assessments: Barthel(mandatory) Dependency (mandatory) Oral Health (mandatory)
- 25. Personal care What arethe wishes of the resident? How would they like to be supported with personal care. Bath or Shower? Foot care, do they need a chiropodist and who will this be as well as frequency of visits. Does the resident need support with oral mouth care? Nail care, does the resident need support with this? Do they like to receive a manicure also? Does the resident need support with shaving/make-up? How do they prefer to be shaved? Does the resident visit the hairdresser and who is this? Does the resident need your help with providing support in getting everything ready for them such as towel toiletries clothing. Who purchases manages toiletries? Do they use moisturaisers? Can they choose clothes?
- 26. Sexuality If they arein a relationship how do we support there partner to feel welcomed and have quality time together Is there a image that they are setting out to achieve daily? Make up? Clean shave? Smart clothing. What is their sexual orientation? What gender do they identify as? Are they in a relationship? Married? Have they got any active sexual need? How can we support them?
- 27. Skin Integrity Linked Assessments: Waterlow(mandatory) MUST (mandatory)
- 28. Skin integrity Any woundsthat we are aware of are to be recorded in this care plan as well as in the wound care plan. Are wounds managed by internal nurses or DNs? Are the district nurse team involved or is a referral needed? How many times are they visiting? Make reference to the district nurse diary. Do they have or need any pressure relieving equipment and what is this?? Do we check that those are functioning correctly daily? MUST DO actions Are they under the care of the dietitian or need a referral? Are the on scheduled turns to reduce pressure areas? MUST DO actions Waterlow assessment to be updated and linked to this care plan. Creams in place that have been prescribed for their use? MUST DO actions
- 29. Sleeping Have they consentedto acoustic monitoring record in the care plan whether they have or haven’t. Also refer to hard copy consent forms. Do they needs turns in the night? Air mattress? What support does the person need to get in/out of bed and get ready for bed. Are they continent and do they continence checks or help to use the toilet during the night? Are they able to use a call bell during the night to call for assistance? Do they sleep well during the night? Do they wake without stress. Do they require any medication? Would they like to be checked visually during the night? What time do they usually go to sleep and wake up? Do they have any routine? Do they sleep in pj/underwear/clothes? Do they want a small light on or do they prefer to sleep in the dark? Do they have a drink before sleeping? Do they have bed rails? Sensor mat? Low profiling bed? Crash mat?
- 30. Things to Remember Scanneddocs: Pre-admission assessment GP summary Any consent LPA Property list BAME risk assessment DoLS (if applicable)
- 31. Things to remember PlannedCare Actions: Please add a ‘MUST DO’ care action for anything that you state in the care plan you do regularly Examples: Moisturising creams (state in the summary where to apply the cream) Checking the air mattress (state in the summary the correct settings) Fluid watch, snacks, weekly weights etc…..
- 32. Things to remember Consent: Youneed a written consent for the Covid-19 swab and photography. If the Resident does not have capacity, the LPA for Health and Welfare can sign the consent. If there is no LPA for Health and Welfare you need to complete an MCA and BI involving the Resident’s family members in the decision. You need a verbal consent documented in the care plan for the administration of medication, sensor mat and bed rails. If the Resident does not have capacity, you need to complete an MCA and BI involving the Resident’s family members in the decision.