Resident Care Plan

Written by: [Your Name]

I. Resident Information

Name: [Resident's Name]
Age: 78 years
Medical Diagnosis: Hypertension, Type 2 Diabetes, Osteoarthritis
Allergies: None known
Primary Physician: [Physician's Name]
Contact Person: [Contact Person's Name]

II. Assessment and Care Planning

Initial Assessment: Conducted within 24 hours of admission, assessing physical, cognitive, and psychosocial status. Includes medical history review, functional assessment, and identification of care needs.
Care Team Meetings: Scheduled monthly with interdisciplinary team members (nurses, therapists, social workers) to review resident progress, update care plans, and address any concerns.
Resident Preferences: Regularly reviewed and documented, including preferences for daily routines, meal choices, activities, and preferred methods of communication.

III. Health Status

Vital Signs Monitoring: Conducted at least daily, or more frequently as indicated by resident's condition or physician orders. Includes monitoring of blood pressure, heart rate, temperature, respiratory rate, and oxygen saturation.
Medication Management: Medications are administered as prescribed, with careful attention to timing, dosage, and potential interactions. Regular medication reviews are conducted to ensure appropriateness and efficacy.
Dietary Needs: Individualized meal plans developed based on dietary restrictions, preferences, and nutritional requirements. Regular monitoring of food intake, hydration status, and weight changes.
Mobility and Exercise: Regular assessment of mobility status and implementation of appropriate exercise programs to maintain or improve strength, balance, and range of motion. Encourage daily walking or participation in tailored exercise classes.

IV. Activities of Daily Living (ADLs)

Personal Hygiene: Assistance provided with bathing, grooming, dental care, and toileting as needed. Respect resident's privacy and dignity during personal care routines.
Dressing and Clothing: Assist with selecting appropriate clothing, dressing, and maintaining personal hygiene standards.
Toileting: Assist with toileting needs, including transferring to and from the toilet, maintaining continence care routines, and providing assistance with hygiene.
Nutrition and Meal Assistance: Offer assistance with feeding, adaptive equipment as needed, and ensure meals are served at appropriate times according to resident preferences and dietary requirements.

V. Therapeutic Interventions

Rehabilitation Services: Coordinate and implement physical therapy, occupational therapy, and speech therapy sessions as prescribed to address functional limitations and promote independence.
Pain Management: Regular assessment of pain levels using standardized scales, administration of pain relief medications as ordered, and implementation of non-pharmacological interventions such as heat therapy or massage.
Psychological Support: Offer emotional support, engage residents in social activities, and provide opportunities for meaningful interactions to enhance mental well-being and reduce feelings of isolation or depression.

VI. Safety Measures

Fall Prevention: Conduct fall risk assessments upon admission and regularly thereafter. Implement environmental modifications, use of assistive devices, and supervise activities to minimize fall risks.
Infection Control: Adhere to strict hand hygiene protocols, use of personal protective equipment, and infection control measures to prevent the spread of infections within the facility.
Emergency Preparedness: Ensure staff are trained in emergency response procedures, conduct regular drills for fire safety, evacuation procedures, and medical emergencies.

VII. Communication and Documentation

Shift Handover: Provide detailed handover between shifts, including updates on resident condition, recent interventions, and any changes in care plans. Use standardized communication tools to ensure consistency and accuracy.
Incident Reporting: Document any incidents, accidents, or changes in resident condition promptly in the electronic health record system. Include relevant details such as date, time, description of event, and actions taken.
Family Updates: Communicate regularly with families regarding resident's progress, upcoming appointments, and any concerns or changes in care plans. Encourage family involvement in care decisions and provide opportunities for family visits and participation in care activities.

VIII. Conclusion

The Resident Care Plan outlined above serves as a blueprint for delivering personalized and holistic care to our elderly residents. By adhering to these guidelines and continuously assessing and adjusting care plans as needed, we aim to promote the well-being and quality of life of each individual under our care.