Individual Care Plan PDF

Individual Care Plan Details Care Plan Name ALTERATION IN HEALTH STATUS D/T HYPERTENSION. Start Date 11/01/2024 End Date Problem(s) ALTERATION IN HEALTH STATUS D/T HYPERTENSION....

Individual Care Plan Details Care Plan Name ALTERATION IN HEALTH STATUS D/T HYPERTENSION. Start Date 11/01/2024 End Date Problem(s) ALTERATION IN HEALTH STATUS D/T HYPERTENSION. Hypertension is high blood pressure, and is most common among adults and the elderly. Left unattended, it can cause serious health problems such as stroke, heart attack, etc. Therefore, it is important to monitor blood pressure on a continued basis. Goal(s) Will maintain blood pressure within acceptable range. Approach(es) Responsible Approach Party 1. Monitor blood pressure as prescribed by MD. 2. Monitor for signs/symptoms of shortness of breath, cyanosis, increased weakness, confusion, headaches, chest pain/ tightness, nosebleeds, numbness/ tingling of extremities, N/DCS dizziness/ lightheadedness, or low blood pressure. 3. Take blood pressure before administration. HOLD medication if systolic blood pressure is under 100mmHg. 4. Administer medication as ordered by MD. > Takes Lisinopril 2.5 mg BID for high blood pressure. HOLD medication if systolic pressure is under 100mmHg > Takes Inderal (Propranolol) to normalize pusle. Take blood pressure and pulse before administration. HOLD medication if systolic pressure is under 100mmHg or pulse is under 80. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 04:47 PM. Page 1 of 1 Individual Care Plan Care Plan Details Care Plan Name ALTERATION IN HEALTH STATUS D/T HYPOTHYROIDISM Start Date 11/01/2024 End Date Problem(s) ALTERATION IN HEALTH STATUS D/T HYPOTHYROIDISM: Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid stimulating hormone The thyroid is a butterfly-shaped gland in the front of your neck. It makes hormones that control the way your body uses energy. Having a low level of thyroid hormone affects your whole body. It can make you feel tired and weak. Goal(s) Health Management - Will maintain Thyroid Stimulating Hormone (TSH) is within normal limits. Approach(es) Responsible Approach Party N/DCS 1. Monitor TSH levels. Lab work as ordered by MD. 2. Administer medication, as ordered by MD > Takes Levothyroxine QD. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 04:49 PM. Page 1 of 1 Individual Care Plan Care Plan Details Care Plan Name COVID-19 Care Start Date 11/01/2024 End Date Problem(s) The individual has tested positive for Coronavirus Disease (COVID-19). Goal(s) Care providers will understand how to implement care and prevent the spread of COVID-19. Individual will be free of complaints and fully recover from COVID-19. Approach(es) Responsible Approach Party Care Providers will follow CDC recommendations and guidelines regarding COVID-19 (see attached). Care Providers to administer medications as ordered by physician. Monitor effectiveness and side effects. Notify MD if any side effects or if medication is not effective. Care Providers to monitor individual for any of the following and notify MD immediately if any occur: Temp 100.4 degrees Fahrenheit or higher, cough, congestion, runny nose, sore throat, muscle pain, confusion, behavior changes, or any changes with the Individual. Care Providers to monitor for any changes;chest pain, persistent pain or pressure in chest, complain of shortness of breath, appears to have difficulty breathing, skin color changes - blueish lips or face, wheezing, gasping for breath, unable to catch breath between coughing episodes, new confusion or inability to arouse, any trouble breathing and CALL 911. Inform EMS that the individual has symptoms of COVID-19 or tested positive. If EMS transports individual to hospital emergency department, make sure the receiving hospital is aware the individual has symptoms or tested positive for COVID-19. Give EMS and hospital all pertinent medical information including contact numbers. Care providers will monitor oxygen saturation daily and document reading in Therap Health Tracking under "vital signs." Report any reading below 90% to primary care physician for further guidance. Care Providers to keep individual in a separate room and designate a bathroom for just that individual's use if available. If there are shared spaced, sanitize properly in between uses. Do not let individual leave home, except to get medical care. If leaving for medical care call ahead to make sure medical office is aware of symptoms. Have individual wear a face mask. Care providers transporting individual to wear a face mask (N95 respirator preferred) during transport and medical appointment. Assist the individual to stay away form others. Prohibit visitors who do not have an essential need to be in the home. Care Providers to assist the individual to cover their coughs and sneezes: Cover their mouth and nose with a tissue when they cough or sneeze. Dispose: Throw used tissues in a lined trash can. Wash hands: Immediately assist Individual to wash their hands with soap and water for at least 20 seconds. If soap and water are not available, clean hands with an alcohol-based hand sanitizer that contains at least 60% alcohol. Have individual clean their hands often Wash hands: Wash hands often with soap and water for at least 20 seconds. This is especially important after blowing nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food. Hand sanitizer: If soap and water are not available, use an alcohol-based hand sanitizer with at least 60% alcohol, covering all surfaces of hands and rubbing them together until they feel dry. Soap and water: Soap and water are the best option, especially if hands are visibly dirty. Avoid touching: Avoid touching eyes, nose, and mouth with unwashed hands. Care Providers to wear appropriate PPE (see CDC guidelines and follow County Public Health instructions). Wear a disposable facemask and gloves when you touch or have contact with the person’s blood, stool, or body Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 04:50 PM. Page 1 of 3 Responsible Approach Party fluids, such as saliva, sputum, nasal mucus, vomit, urine. Throw out gloves after using them and masks if soiled. If masks are not soiled, and supplies are short, they can be reused. Ideally healthcare workers interacting with COVID-19 affected individuals would have an N95 respirator (If available) When removing personal protective equipment, first remove and dispose of gloves. Then, immediately clean your hands with soap and water or alcohol-based hand sanitizer. Next, remove facemask, and immediately clean your hands again with soap and water or alcohol-based hand sanitizer. If re-using mask, store in a bag between uses. Place all used disposable gloves, facemasks, and other contaminated items in a lined container before disposing of them with any other household waste. Clean your hands (with soap and water or an alcohol-based hand sanitizer) immediately after handling these items. Soap and water should be used preferentially if hands are visibly dirty. Do not share: Do not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people in the home. Wash thoroughly after use: After using these items, wash them thoroughly with soap and water or put in the dishwasher. USE DISPOSABLE UTENSILS, PLATES, BOWLS< AND CUPS WHEN EVERY POSSIBLE. Wash laundry thoroughly. Immediately remove and wash clothes or bedding that have blood, stool, or body fluids on them, as well as any items that come in contact with the infected individual. Wear disposable gloves while handling soiled items and keep soiled items away from your body. Clean your hands (with soap and water or an alcohol-based hand sanitizer) immediately after removing your gloves. Read and follow directions on labels of laundry or clothing items and detergent. In general, using a normal laundry detergent according to washing machine instructions and dry thoroughly using the warmest temperatures recommended on the clothing label. Do not forget to sanitize the laundry basked according to the hard surface instructions. Care Providers to clean high-touch surfaces in “sick room” and bathroom every day; Staff should wear a mask and wait as long as possible after the sick person has used the bathroom. Clean and disinfect: Routinely clean high-touch surfaces in individual's “sick room” and bathroom. Have another staff clean and disinfect surfaces in common areas. High-touch surfaces include phones, remote controls, counters, tabletops, doorknobs, bathroom fixtures, toilets, keyboards, tablets, and bedside tables. Clean and disinfect areas that may have blood, stool, or body fluids on them. Household cleaners and disinfectants: Clean the area or item with soap and water or another detergent if it is dirty. Then, use approved household disinfectant. Be sure to follow the instructions on the label to ensure safe and effective use of the product. Many products recommend keeping the surface wet for several minutes to ensure germs are killed. Many also recommend precautions such as wearing gloves and making sure you have good ventilation during use of the product. Care Providers to assist individual to stay involved in activities they enjoy. Keep any supplies in the room for that individual's use only. Assist individual to make phone calls or other forms of communication with family, friend, and housemates. As much as possible use only disposable products in the individual's room. Follow manufacturer's cleaning and disinfecting guidelines for any non-disposable items. Ensure the same care providers are assigned to individual to prevent control of infection. Care providers to follow and implement County Public Health and physician's instructions for discontinuing "home isolation". If guidelines are not given then follow the following CDC guidelines: People with COVID-19 who have stayed in their bedrooms (home isolated) can stop home isolation under the following conditions: 1. If individual will not have a test to determine if they are still contagious, they can leave their bedroom after these three things have happened: a. They have had no fever for at least 72 hours (that is three full days of no fever without the use medicine that reduces fevers), AND b. other symptoms have improved (for example, cough or shortness of breath have improved), AND c. at least 10 days have passed since their symptoms first appeared. 2. If individual will be tested to determine if they are still contagious, they can leave bedroom after these three things have happened: a. They no longer have a fever (without the use medicine that reduces fevers), AND b. other symptoms have improved (for example, cough or shortness of breath have improved), AND c. individual has received two negative tests in a row, 24 hours apart. Monitor CDC guidelines for any updates. Care Providers to notify RN of any questions or concerns regarding this plan or Individual’s care. Attachment(s) Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 04:50 PM. Page 2 of 3 Individual Care Plan Care Plan Details Care Plan Name DISTURBED SLEEP PATTERN Start Date 11/01/2024 End Date Problem(s) DISTURBED SLEEP PATTERN R/T NEUROLOGICAL DYSFUNCTION AS EVIDENCED BY EPISODES OF INSOMNIA, WAKING UP AND CRYING AT NIGHT Goal(s) Will achieve optimal amounts of sleep as evidenced by rested appearance and improvement in establishing a regular sleep pattern to prevent insomnia within the next 3 months. Approach(es) Responsible Approach Party 1. Follow as consistent a daily scheduled for retiring and arising as possible. 2. Arrange environment to be conducive to sleep or rest (quiet, comfortable, temperature, ventilation, darkness). 3. Limit staff interruptions during sleep hours. 4. Discourage pattern of daytime naps unless deemed necessary to meet sleep requirements or if part of client’s usual N/DCS pattern. 5. Increase daytime physical activities as indicated to promote sleep. 6. If more than 2 days in a row of less than 4 hours sleep, notify RN for further instructions. 7. Notify MD if insomnia is getting so frequent that it interrupts with client’s daily activities for further evaluation and management. 8. Administer medication as ordered by MD for insomnia. > If client has insomnia, monitor client as client will engage in SIB, fecal smearing and gagging. > Takes Melatonin for insomnia. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 04:51 PM. Page 1 of 1 Individual Care Plan Care Plan Details Care Plan Name HIGH RISK FOR INJURY D/T CLIENT INFLICTING SELF-INJURIOUS BEHAVIOR R/T DIAGNOSES Start Date 11/01/2024 End Date Problem(s) HIGH RISK FOR INJURY D/T CLIENT INFLICTING SELF-INJURIOUS BEHAVIOR R/T DIAGNOSES OF INTELLECTUAL DISABILITIES, INFANTILE AUTISM, ANXIETY, DEPRESSION, INTERMITTENT EXPLOSIVE DISORDER, AND SEVERE SIB > Has several behaviors including anxiety, depression (cyclical refusing to eat with weight loss, growling, prolonged sleeping), fecal smearing and eating, PICA, resistiveness, self-gagging, SIB (biting arms/ finger/ hand/ lips, eye poking/ rubbing, chin/ ear rubbing, face punching/ slapping, head banging, hitting head with knees, scratching till leaves a mark), and tantrums (crying/ screaming/ sobbing, clothes stripping, foot stomping, intentional incontinence, SIB to face, throwing objects). > Has hx of episodes of increase in the number of incidences of SIB injury and severity (eyes poking/ scratching) when she was wearing a helmet with face guard. Client refuses to wear. Goal(s) Will be able to redirect client during episodes of self-injurious behavior within the next 3 months. Will be able to prevent injury r/t behavior problems within the next 3 months. Approach(es) Responsible Approach Party 1. Approach client in a calm manner and maintain a consistent schedule to address and meet needs. 2. Check and assist with restroom/toileting needs. Keep clean and dry as possible to prevent fecal smearing and PICA. 3. Provide cheerful conversation, positive reassurance, and activities of choice/interest to redirect attention from inappropriate behavior. 4. Provide a safe environment. Appropriately lock all sharps, fire-causing tools and instruments and N/DCS poisonous substances. 5. Identify environmental stimuli that cause increased agitation or anxiety, remove client when possible from external stimuli that appear to exacerbate or trigger behavior. 6. Administer medication as ordered by MD. 7. Documents and report incidences as appropriate to RN for follow-up. Report to MD severe incidences for further evaluation and monitoring. 8. RN/MD will evaluate medication effectiveness every physician’s review. Monitor for side effects of psychotropic meds and report to RN/MD as needed. > Monitor client for SIB and initiate 1:1 monitoring of client when episodes of SIB escalate to ensure safety to prevent injury. > Use blocking technique, placing hand between her face and hand or object ,to stop sudden and/or severe SIB along with implementation of verbal redirection and utilization of interventions (i.e. change activity or location). > Monitor client for self-gagging behavior and episodes of vomiting and possible bleeding. > Takes Abilify (Aripiprazole) for autism, anxiety, SIB, and tantrums, Buspirone (Buspar) for autism, anxiety, SIB, and tantrums, Divalproex Sodium (Depakote) for anxiety, Naltrexone for SIB, Olanzapine (Zyprexa) for autism, SIB, and tantrums, and Venlafaxine (Effexor XR) for depression. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 04:52 PM. Page 1 of 1 Individual Care Plan Care Plan Details Care Plan Name HIGH RISK FOR INJURY D/T CLIENT INFLICTING SELF-INJURIOUS BEHAVIOR R/T DIAGNOSES Start Date 11/01/2024 End Date Problem(s) HIGH RISK FOR INJURY D/T CLIENT INFLICTING SELF-INJURIOUS BEHAVIOR R/T DIAGNOSES OF INTELLECTUAL DISABILITIES, INFANTILE AUTISM, ANXIETY, DEPRESSION, INTERMITTENT EXPLOSIVE DISORDER, AND SEVERE SIB > Has several behaviors including anxiety, depression (cyclical refusing to eat with weight loss, growling, prolonged sleeping), fecal smearing and eating, PICA, resistiveness, self-gagging, SIB (biting arms/ finger/ hand/ lips, eye poking/ rubbing, chin/ ear rubbing, face punching/ slapping, head banging, hitting head with knees, scratching till leaves a mark), and tantrums (crying/ screaming/ sobbing, clothes stripping, foot stomping, intentional incontinence, SIB to face, throwing objects). > Has hx of episodes of increase in the number of incidences of SIB injury and severity (eyes poking/ scratching) when she was wearing a helmet with face guard. Client refuses to wear. Goal(s) Will be able to redirect client during episodes of self-injurious behavior within the next 3 months. Will be able to prevent injury r/t behavior problems within the next 3 months. Approach(es) Responsible Approach Party 1. Approach client in a calm manner and maintain a consistent schedule to address and meet needs. 2. Check and assist with restroom/toileting needs. Keep clean and dry as possible to prevent fecal smearing and PICA. 3. Provide cheerful conversation, positive reassurance, and activities of choice/interest to redirect attention from inappropriate behavior. 4. Provide a safe environment. Appropriately lock all sharps, fire-causing tools and instruments and N/DCS poisonous substances. 5. Identify environmental stimuli that cause increased agitation or anxiety, remove client when possible from external stimuli that appear to exacerbate or trigger behavior. 6. Administer medication as ordered by MD. 7. Documents and report incidences as appropriate to RN for follow-up. Report to MD severe incidences for further evaluation and monitoring. 8. RN/MD will evaluate medication effectiveness every physician’s review. Monitor for side effects of psychotropic meds and report to RN/MD as needed. > Monitor client for SIB and initiate 1:1 monitoring of client when episodes of SIB escalate to ensure safety to prevent injury. > Use blocking technique, placing hand between her face and hand or object ,to stop sudden and/or severe SIB along with implementation of verbal redirection and utilization of interventions (i.e. change activity or location). > Monitor client for self-gagging behavior and episodes of vomiting and possible bleeding. > Takes Abilify (Aripiprazole) for autism, anxiety, SIB, and tantrums, Buspirone (Buspar) for autism, anxiety, SIB, and tantrums, Divalproex Sodium (Depakote) for anxiety, Naltrexone for SIB, Olanzapine (Zyprexa) for autism, SIB, and tantrums, and Venlafaxine (Effexor XR) for depression. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 04:53 PM. Page 1 of 1 Individual Care Plan Care Plan Details Care Plan Name IMPAIRED VERBAL COMMUNICATION R/T COGNITIVE IMPAIRMENT AS EVIDENCED BY INABILITY TO VOCALIZE WORDS Start Date 11/01/2024 End Date Problem(s) IMPAIRED VERBAL COMMUNICATION R/T COGNITIVE IMPAIRMENT AS EVIDENCED BY INABILITY TO VOCALIZE WORDS Client is nonverbal and has difficulty expressing her needs and wants. Goal(s) Client needs are met through established means of communication within the next 3 months. Staff will be able to recognize signs and symptoms of illness within the next 3 months. Approach(es) Responsible Approach Party 1. Anticipate client’s daily needs with attention to nonverbal cues and with recognition of signs and symptoms of illness, pain or discomfort. 2. Provide positive reassurance, encourage client’s attempts to communicate, and praise attempts and achievements with every opportunity. 3. Speak slowly and distinctly, repeating keywords to prevent confusion. 4. N/DCS Give concrete directions that the client is capable of doing. 5. Place important objects within reach. 6. Supplement verbal communication with meaningful gestures and artifacts (objects) as needed to enhance communication. 7. Notify MD for any significant changes in condition for further evaluation and management. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 04:54 PM. Page 1 of 1 Individual Care Plan Care Plan Details Care Plan Name POTENTIAL OF DRUG RELATED COMPLICATION ASSOCIATED WITH USE OF PSYCHOTROPIC DRUGS Start Date 11/01/2024 End Date Problem(s) POTENTIAL OF DRUG-RELATED COMPLICATIONS ASSOCIATED WITH THE USE OF PSYCHOTROPIC DRUGS Goal(s) Prevent Side Effects - Will receive medication/management to address behaviors and/or psychiatric conditions with the fewest side effects from prescription medication Approach(es) Responsible Approach Party 1. Periodic psych evaluation. 2. Administer medication as ordered by MD. 3. Monitor for adverse side effects, ie tremors, rigidity, decreased muscle movement, involuntary jerking, facial twitches, weight loss, decreased appetite. 4. Document and report observed side effects to RN/MD or admin/licensee as soon as possible. > Takes Abilify (Aripiprazole), Buspirone (Buspar), Divalproex Sodium (Depakote), Naltrexone, Olanzapine (Zyprexa), Venlafaxine (Effexor XR). > Takes Melatonin for insomnia and improve sleep cycle. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 04:54 PM. Page 1 of 1 Individual Care Plan Details Care Plan Name RISK FOR ASPIRATION R/T HX OF ASPIRATION PNEUMONIA Start Date 11/01/2024 End Date Problem(s) RISK FOR ASPIRATION R/T HX OF ASPIRATION PNEUMONIA Risky eating behavior. Eats too fast, swallows without chewing and stuffs mouth too full. Goal(s) 1. Safely consume meals without aspiration. 2. No episodes of choking. Approach(es) Responsible Approach Party Know and Monitor for and report signs and symptoms of choking. First signs: coughing, gag, vomiting, gurgling, shortness of breath, bluish color around the lips. Signs of aspiration pneumonia: fast breathing or heart rate, chest pain, DCS lots of mucus in the mouth, reduced alertness and decreased responsiveness, low grade fever, dehydration, weight loss, infection in the throat, nose or lungs. DCS Report signs of aspiration to RN, GERs team, PCP. DCS If choking blocks airway call 911 and start rescue methods of heimlich maneuver. If vomiting occurs assist the individual to upright position or if lethargic or unable to sit upright lay them on their side to DCS prevent aspiration. Document temperature, respirations and heart rate BID for 3 days following possible aspiration or choking incident. DCS Report abnormal assessment values to RN/ administration immediately. Temperature normals are 97.6-99.9. Respiration at rest 12-20 per minute. Heart rate at rest normal values 60-100 beats per minute. Monitor individual during meals, verbally direct individual to chew properly, eat slowly, take small bites and sips of DCS drinks in between every 2-3 bites of food. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 04:56 PM. Page 1 of 1 Individual Care Plan Care Plan Details Care Plan Name RISK FOR CONSTIPATION Start Date 11/01/2024 End Date Problem(s) RISK FOR CONSTIPATION R/T NEUROGENIC DISORDER AND MEDICATION REGIMEN Goal(s) Will have a minimum of 1 bowel movement every 3 days within the next 3 months. Approach(es) Responsible Approach Party 1. Monitor and record bowel movements on a daily basis. 2. Encourage adequate fluid intake of 2000-3000 mL/day if not medically contraindicated. 3. Adhere to a dietary regimen as ordered. 4. Encourage increased fiber in a diet, and physical activity and regular exercise as tolerated. Offer prune juice twice a day. 4. Report for s/s of constipation. Give N/DCS bowel regimen as ordered by MD. Monitor for effectiveness. 5. Assess for abdominal distention and s/s of bowel impaction. 6. Report to MD any significant changes in bowel function for further evaluation and management. 7.Administer medication as ordered by MD. > Takes MOM (Milk of Magnesium) 30 mL, if no BM in 3 days as needed, Docusate Sodium (DOK) BID, *MAY HOLD FOR LOOSE STOOL, Senna 8.5 mg, 2 tablets at bedtime as needed, if NO BM after Day 2, and Fiber Laxative (Metamucil) BID for constipation. > Takes Acidophilus 175mg daily for bowel maintenance. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 05:00 PM. Page 1 of 1 Individual Care Plan Form ID Care Plan Details Care Plan Name RISK FOR IMBALANCED NUTRITION LESS THAN BODY REQUIREMENTS Start Date 11/01/2024 End Date Problem(s) RISK FOR IMBALANCED NUTRITION LESS THAN BODY REQUIREMENTS R/T DECREASED APPETITE, REFUSAL OF SOME MEALS AND HX OF CYCLIC LOSS OF APPETITE R/T DIAGNOSIS OF DEPRESSION & M/B DYSPHAGIA Goal(s) Will be able to maintain intake food and fluids sufficient to maintain within 10% of ideal body weight within the next 3 months. Approach(es) Responsible Approach Party 1. Monitor and record meal intake daily. Weight monthly or as needed. 2. Assist client with meals while promoting independence in self-feeding. 3. Provide a pleasant environment, facilitate proper position, and good oral hygiene and dentition. 4. Provide companionship during mealtime. 5. Encourage adequate fluid intake to prevent dehydration. Watch for s/sx of dehydration. 6. Discourage beverages that are caffeinated or carbonated. 7. Provide a balance of N/DCS activities and rest to prevent over tiring and fatigue. 8. Administer regular dietary supplement as ordered by MD. 9. Refer to dietitian quarterly and as needed for dietary modifications and needs. 10. Monitor levels for lab work as ordered by MD. 11. Report to MD episodes of meal refusals or poor intake if it becomes frequent that may cause a decrease in weight of 5 lbs or more in a month. > Takes Ascorbic Acid (Vitamin C) for health maintenance, Multivitamin for health maintenance, and Carnation Instant Breakfast, Ensure or equivalent, as ordered with meals for nutritional supplement. > Takes Protein powder 2 scoops (21g) / day, a nutritional supplement to increase protein intake/stores increased amount on 8/2/24. > Takes Thick-It for supplement and ease in swallowing. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 05:01 PM. Page 1 of 1 Individual Care Plan Care Plan Details Care Plan Name RISK FOR IMBALANCED NUTRITION R/T CLIENT'S SIB OF GAGGING AND VOMITING WHEN FRUSTRATED Start Date 11/01/2024 End Date Problem(s) RISK FOR IMBALANCED NUTRITION R/T CLIENT'S SIB OF GAGGING AND VOMITING WHEN FRUSTRATED Goal(s) Prevent GI Bleeding & Aspiration Risk Approach(es) Responsible Approach Party Client has self-gagging behavior by putting her four fingers down her throat. 1. Provide a consistent daily routine and N/DCS make client aware of new changes and surroundings when needed. 2. Monitor closely for episodes of vomiting, possible bleeding and her safety. Notify RN immediately of vomiting episodes. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 05:02 PM. Page 1 of 1 Individual Care Plan Care Plan Details Care Plan Name RISK FOR IMPAIRED SKIN INTEGRITY D/T INCONTINENCE OF BOWEL AND BLADDER Start Date 11/01/2024 End Date Problem(s) RISK FOR IMPAIRED SKIN INTEGRITY D/T INCONTINENCE OF BOWEL AND BLADDER Goal(s) Will be free from skin breakdown r/t incontinence and itching within the next 3 months. Approach(es) Responsible Approach Party 1. Assist with turning and repositioning q 2 hours and PRN. 2. Monitor and prompt client to void q 2 hrs or as needed along with checking and changing incontinent briefs and provide good perineal care PRN. 3. Keep clean and dry. 4. Shower daily as scheduled, apply lotion to skin to enhance circulation and maintain good skin lubrication. 5. Maintain N/DCS good hydration. Encourage adequate fluid intake. 6. Report to MD as clinically indicated for any signs of skin breakdown such as redness, irritation, or excoriation for proper skin management. 7. Administer medication as prescribed by MD. > Client wears incontinent briefs as ordered by MD. > Takes Banophen [Diphenhydramine (Benadryl)] PRN for itching. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 05:03 PM. Page 1 of 1 Individual Care Plan Care Plan Details Care Plan Name SELF-CARE DEFICIT R/T NEED FOR ASSISTANCE WITH ADL’S D/T DIAGNOSIS Start Date 11/01/2024 End Date Problem(s) SELF-CARE DEFICIT R/T NEED FOR ASSISTANCE WITH ADL’S D/T DIAGNOSIS OF PROFOUND INTELLECTUAL DISABILITIES, INFANTILE AUTISM, ANXIETY, DEPRESSION, INTERMITTENT EXPLOSIVE DISORDER, AND SEVERE SIB Goal(s) Will safely perform to maximum ability self-care activities, including ADLs, daily grooming, and comprehensive hygiene care within the next 3 months. Approach(es) Responsible Approach Party 1. Client needs verbal prompts and physical assistance in completing ADL’s. To facilitate independence, assist as needed and encourage the client to participate in the completion of ADL’s as able. 2. Use consistent routines and allow adequate time for the client to complete tasks. 3. Provide positive reinforcement for all activities attempted. 4. Reevaluate regularly to be certain that the client is maintaining skill level and remains safe in the environment. 5. N/DCS Maintain good perineal care. 6. Provide good skin care daily to prevent skin irritations. 7. Shower as scheduled. Apply deodorant after each bathing. Comb hair daily and as needed. 8. Provide oral care in AM and HS. 9. Use appropriate clothing for weather and occasion with proper fit and size. 10. Keep clean and well groomed daily. 11. Provide nail care for hands and feet weekly and PRN. Attachment(s) Reviews Team Meeting Discussions Generated from Therap 'Individual Care Plan' by N/A , on 10/31/2024 05:06 PM. Page 1 of 1