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Morningside House Standards of Care Interim February 13, 2008
Morningside House Standards of Care Interim February 13, 2008
Standards of Care
Interim February 13, 2008
TABLE OF CONTENTS
Page #
Activities...........................................................................................................3
ADL: Dressing and Hygiene............................................................................3
ADL: Mobility/ROM Contracture....................................................................4
ADL: Elimination............................................................................................4
ADL: Oral Hygiene..........................................................................................4
Advance Directives...........................................................................................5
Communication With Resident.....................................................................5, 6
Communication With Cognitively Impaired Resident.....................................6
Discharge Planning.......................................................................................6, 7
Escorted/Unescorted Day Pass/Overnight
Therapeutic Leave of Absence.......................................................................7
Medical Condition: Dialysis........................................................................7, 8
Medical Condition: Seizure Disorder...............................................................8
Medications: Psychotropic Drug Use...............................................................8
Medications: Self-Medication..........................................................................9
Nutrition/Hydration..........................................................................................9
Pain ............................................................................................................9, 10
Palliative Care/End of Life Care Plan/Hospice..............................................10
Psychosocial Needs: Potential for Verbal or Physical Aggression.................11
Psychosocial Well-Being ...............................................................................11
Safe Swallowing.............................................................................................12
Safety: At Risk for Elopement .......................................................................12
Safety: Oxygen Use........................................................................................13
Safety: Risk for Falls.....................................................................................13
Skin Integrity: Actual Skin Breakdown..........................................................14
Skin Integrity: At Risk for Skin Breakdown...................................................14
Sleep...............................................................................................................14
Spirituality Care Plan................................................................................14, 15
Tube Feeding..................................................................................................15
2
ACTIVITIES
3
ADL: MOBILITY/ROM CONTRACTURE
ADL: ELIMINATION
Incontinence
Intervention Responsible Discipline
Evaluate for underlying causes of incontinence Nursing/Medical
Refer to specialist for treatment Nursing
Provide toileting plan that supports resident’s lifestyle and Nursing
voiding pattern Nursing
Utilize appropriate absorbency products Nursing
Toilet resident promptly upon request Nursing
Assist resident in toileting, hygiene and clothing as needed Nursing
Medication as ordered Nursing/Medical
Modify clothing and environment to provide easy Nursing/Rehab
access to toilet
Provide and encourage fluid intake to maintain bladder tone Nursing/Dietary
4
ADVANCE DIRECTIVES
5
COMMUNICATION WITH RESIDENT—Continued
DISCHARGE PLANING
6
DISCHARGE PLANING—Continued
7
MEDICAL CONDITION: DIALYSIS—Continued
8
MEDICATIONS: SELF-MEDICATION
NUTRITION/ HYDRATION/DENTAL
PAIN
9
PAIN—Continued
Intervention Responsible Discipline
Inform/provide info re: pain management to resident/family. Nursing/Social Work/
Medical
Observe for verbal/nonverbal expressions of pain. All
Encourage resident to inform staff of any changes in frequency, All
intensity and/or pain site (if able).
Provide non pharmacologic/holistic Interventions. RT/Social Work/Dietary
Pain is whatever the resident indicates All
10
PSYCHOSOCIAL NEEDS:
POTENTIAL FOR VERBAL OR PHYSICAL AGGRESSION
PSYCHOSOCIAL WELL-BEING
11
SAFE SWALLOWING
12
SAFETY: OXYGEN USE
13
SKIN INTEGRITY: ACTUAL SKIN BREAKDOWN
SLEEP
TUBE FEEDING
15