PLAN OF CARE

SN FREQUENCY:
SKILLED OBSERVATION/EVALUATION, ASSESSMENT OF ALL SYSTEMS
AND VITAL SIGNS WITH SPECIAL ATTENTION TO: ENDOCRINE SYSTEM.
SN TO ASSESS ENDOCRINE STATUS, PATIENT'S ABILITY TO PERFORM OWN
DIABETIC CARE AND POTENTIAL TO LEARN/PERFORM OWN CARE.
SN TO PERFORM BSL MONITORING VIA GLUCOMETER PRIOR INSULIN
ADMINISTRATION, PREPARE/ADMINISTER INSULIN BID/DAILY AS
FOLLOWS:

SN TO ROTATE INJECTION SITE USING SITE ROTATION METHOD,

ASEPTIC TECHNIQUES, UNIVERSAL PRECAUTIONS AND DISPOSE OF
SHARPS PROPERLY FOLLOWING BIOMEDICAL WASTE PROTOCOL.
SN TO NOTIFY PHYSICIAN IF BSL LESS THAN 70 MG/DL OR GREATER
THAN 350 MG/DL, ASSESS AND NOTIFY ANY DEVELOPED COMPLICATIONS
FROM DIABETES.
PATIENT IS UNABLE TO PERFORM OWN GLUCOSE MONITORING AND
UNABLE TO PREPARE/SELF ADMINISTER INSULIN DUE TO: IMPAIRED
VISION, PATIENT HAS DIFFICULTY SEEING FINE LINES IN SYRINGES
POOR MANUAL DEXTERITY, POOR HAND EYE COORDINATION, WEAK
HAND GRIPS, AND REFUSES TO SELF INJECT.
NO CARE GIVER IS AVAILABLE TO ASSIST THE PATIENT WITH CARE.
SN TO INSTRUCT PATIENT ON MANAGEMENT OF DIABETES,
PREPARATION/ADMINISTRATION OF INSULIN , MEDICATION REGIMEN,
NEW MEDICATIONS, SIDE/ADVERSE EFFECTS, HYPO/HYPERGLYCEMIA
AND CORRECTIVE MEASURES, SAFETY/EMERGENCY MANAGEMENT, AND
FOLLOW UP WITH PHYSICIAN.
SN TO SUPERVISE AIDE VISITS EVERY 14 DAYS, WITH PATIENT'S
APPROVAL AND NOTIFY PHYSICIAN OF ANY SIGNIFICANT FINDINGS.

AIDE CARE:
SN TO PERFORM INITIAL EVALUATION FOR HOME HEALTH SERVICES,
ASSESS PATIENT'S NECESSITY OF HOME HEALTH SERVICES, ABILITY TO
PERFORM OWN PERSONAL CARE AND CAREGIVER'S AVAILABILITY TO
ASSIST THE PATIENT WITH CARE.
SN TO ASSESS PATIENT'S PERFORMANCE OF ACTIVITIES OF DAILY LIVING,
EATING PROCESS, TRANSFER/AMBULATION, TOILETING, COMUNICATION,
PREPARING LIGHT/FULL MEALS, LIGHT HOUSEKEEPING, PERSONAL
LAUNDRY, HANDLING MONEY, USE OF TELEPHONE, READING/WRITING,
MANAGE OF MEDICATION AND SAFETY TO PERFORM OWN CARE.
HOME HEALTH AIDE TO OBSERVE, RECORD, AND REPORT ANY
SIGNIFICANT CHANGES IN TPR, APPETITE, SKIN CONDITION, MOOD/
ATTITUDE, PAIN, SWELLING, AND LBM. AIDE TO PROVIDE
ASSISTANCE WITH PERSONAL CARE AND ADL'S, SUCH AS: SHOWER
WITH ASSIST, PERINEAL CARE, HAIR CARE-BRUSH/SHAMPOO PRN,
ORAL HYGIENE-CLEAN/FILE PRN, SKIN CARE, ASSIST WITH DRESSING
GROOMING, DEODORANT, CLEAN AND STRAIGHTEN KITCHEN, BEDROOM,
BATHROOM, CHANGE LINEN PRN, PREPARE/SERVE MEALS AS NEEDED.

WOUND CARE:

SN TO ASSESS INTEGUMENTARY STATUS.

SN TO PERFORM WOUND CARE (FREQ) TO WOUND/ULCER IN (LOCATION)
WHICH MEASURES AS FOLLOWS:
L: CM X W: CM X D: CM, WITH __ AMOUNT OF __
DRAINAGE, __ ODOR, __ EDEMA, __ UNDERMINING/TUNNELING,
PERIWOUND IS INTACT AND WOUND BED IS PINK WITH GRANULATION
TISSUE.
SN TO PROVIDE THE FOLLOWING WOUND CARE: " "
FOLLOWING ASEPTIC TECHNIQUES AND UNIVERSAL PRECAUTIONS.
SN TO ASSESS WOUND FOR SIGN/SYMPTOMS OF
HEALING/INFECTION/COMPLICATIONS, AND REPORT WOUND
STATUS/PROGRESS TO PHYSICIAN __________________
SN TO MEASURE WOUND EVERY WEEK, ASSESS DRAINAGE ON EACH VISIT
FOR AMOUNT, COLOR, ODOR, AND CONSISTENCY.
INSTRUCT PATIENT IN WOUND CARE PROCEDURE, WAYS TO PROMOTE
WOUND HEALING, SIGNS /SYMPTOMS OF HEALING/COMPLICATIONS TO
REPORT TO PHYSICIAN.
PATIENT IS UNABLE TO PERFORM OWN WOUND CARE DUE TO:
_______________________________________________________________________
___________________________________________________________________
NO CARE GIVER AVAILABLE TO ASSIST THE PATIENT WITH WOUND CARE.

PEG TUBE CARE

SN TO PERFORM PEG SITE CARE AND PEG FEEDINGS OF ____ VIA ___
FLUSHING WITH _____CC OF WATER AFTER EACH FEEDING, AND WITH
______CC OF WATER AFTER MEDICATION ADMINISTRATION.
SN TO TEACH AND ASSESS PATIENT / CAREGIVER ABILITY TO
PERFORM PEG FEEDING AND PEG SITE CARE INCLUDING PREPARATION
AND STORAGE OF FEEDING, EQUIPMENT CARE, FLUSHING TECHNIQUE,
FLOW RATE CALCULATION, ASSESSMENT OF PEG SITE FOR SIGNS OF
INFECTION, PRN VISITS FOR CLOG, LEAK OF MALFUNCTION.

PHYSICAL THERAPY

RPT TO PERFORM INITIAL EVALUATION WITH FOLLOW UP VISITS

FOR PHYSICAL THERAPY SERVICES.
RPT TO ASSESS/EVALUATE MUSCLE STRENGH, ROM, AMBULATION,
BED MOBILITY, TRANSFER ABILITY, COORDINATION, BALANCE,
ENDURANCE, DISEASE PROCESS, PAIN, HOME SAFETY AND ADL'S.
RPT TO PROVIDE PATIENT WITH HOME EXERCISE PROGRAM. :
RPT TO SUPERVISE PTA/AIDE VISITS EVERY 14 DAYS.

FOLEY CATHETER

SN TO PERFORM FOLEY MAINTENANCE (FREQ) UTIIZING ____FR/FOLEY

WITH ____CC/BALLO ___ PRN VISITS FOR CLOG, LEAK, OR
ACCIDENTAL REMOVAL. LAST FOLEY CHANGE PERFORMED ON (DATE).
SN TO IRRIGATE FOLEY WITH ___CC OF ____ (FREQ) AND PRN FOR
_____. SN TO TEACH AND ASSESS PATIENT / CAREGIVER ABILITY TO
CARE FOR INDWELLING CATHETER. *FOR INFUSIONS/IVS* SN TO
ADMINISTER (MED) VIA (CATH) (FREQ), AS PER PHYSICIAN'S
ORDERS, SEE BOX 10. SN TO FLUSH (CATH) W/(NSS) PRIOR TO ADMI

GOALS

SN GOALS:

1) PATIENT WILL VERBALIZE UNDERSTANDING OF DISEASE PROCESS

AND CURRENT HEALTH STATUS.
2) PATIENT WILL VERBALIZE UNDERSTANDING OF THERAPEUTIC DIET
3) PATIENT WILL VERBALIZE UNDERSTANDING OF S/S TO REPORT TO
PHYSICIAN.
4) PATIENT WILL RETURN TO OPTIMUM ENDOCRINE STATUS W/O
COMPLICATIONS OR FURTHER PROGRESSION OF DISEASE PROCESS.

PT GOALS:

RPT GOALS:
1) PATIENT WILL DEMONSTRATE ABILITY TO FOLLOW HEP.
2) PATIENT WILL ATTAIN MAXIMUM JOINT MOBILITY AND MUSCLE
STRENGH.
3) PATIENT WILL BE INDEPENDENT OR BE ABLE TO PARTICIPATE
IN ACTIVITIES OF DAILY LIVING.
4) PATIENT WILL BE COMFORTABLE WITH IN HOME SETTINGS.
5) OPTIMUM FUNCTION WILL BE ATTAINED AND MAINTAINED.

AIDE GOALS:

AIDE GOAL: AIDE WILL PROVIDE PERSONAL CARE IN ORDER TO

MAINTAIN AN OPTIMAL LEVEL OF PATIENT'S PERSONAL HYGIENE. THE
PATIENT WILL REMAIN SAFE, CLEAN AND COMFORTABLE WITH
EFFECTIVE CARE; PERSONAL CARE NEEDS WILL BE MET.

WOUND CARE GOALS

SN GOAL: ONGOING PATIENT AND CAREGIVER WILL DEMONSTRATE

COMPLIANCE WITH DIABETIC CARE AND INSTRUCTIONS; WILL
IDENTIFY S/S OF HYPO/HYPERGLYCEMIA AND MEASURES TO PREVENT
DIABETIC COMPLICATIONS. PATIENT WILL LEARN GOOD SKIN CARE
AND PREVENT ANY SKIN BREAKDOWN. PATIENT WILL DEMONSTRATE
INCREASED HEALING PROCESS WITHOUT ANY S/S OF INFECTION OR
OTHER COMPLICATIONS.

BLOOD PRESSURE

SKILLED OBSERVATION/EVALUATION, ASSESS VITAL SIGNS AND

SYMPTOMS OF COMPLICATIONS, WITH SPECIAL ATTENTION TO
CARDIOVASCULAR SYSTEM. SN TO ASSESS CARDIOVASCULAR STATUS,
MONITOR BLOOD PRESSURE ON EACH NURSING VISIT, AND MANTAIN
RECORD OF THE SAME, CALL PHYSICIAN IF BLOOD PRESSURE GREATER
THAN 140/90 MMHG OR LOWER THAN 100/60 MMHG. SN TO ASSESS FOR
SIGNS/SYMPTOMS OF UNCONTROLLED HYPERTENSION: TINNITUS,
DIZZINESS, OR NASAL BLEEDING. SN TO ASSESS FOR IRREGULAR HR,
PALPITATIONS, TACHYCARDIA OR BRADYCARDIA, FLUID RETENTION OR
EDEMA. SN TO INSTRUCT PATIENT ON DISEASE PROCESS/COMPLICATIONS,
PROGRESS OF DISEASE, DIET AND COMPLIANCE WITH NUTRITIONAL
REQUIREMENT, NEW MEDICATIONS, SIDE/ADVERSE EFFECTS TO REPORT
TO PHYSICIAN, WHEN TO DISCONTINUE MEDICATION, AND ADEQUATE
USE, SAFETY/EMERGENCY MANGEMENT, AND FOLLOW UP WITH
PHYSICIAN. SN TO REPORT ANY SIGNIFICANT FINDINGS TO
NURSE/AGENCY.