Developing and updating care plans to ensure they include the required information takes a lot of staff time and attention. Unfortunately, they don’t usually live up to their potential for day to day usefulness and practicality.
To help address this, we’ve developed a Care Plan Snapshot…a “Readers Digest” version of a care plan that highlights the key information that a GNA or other caregiver would find most helpful day to day. It includes short and long terms goal(s), guidance on ADL care that helps residents maintain or improve function, behavioral issues with suggested approaches to care, and motivational ideas based on a resident’s interests. All in just a few pages!
Below is an example of a Care Plan Snapshot for “Mr. WXYZ”, along with an example of a completed capability test for him, which guided the development of the care plan’s goals and ADL care approaches. We invite you to take a look, share with staff, and discuss how this might be beneficial. Feel free to use and adapt as you’d like for your facility. For example, if family members are involved with a resident’s care, you may want to add a section on what family members can do during visits to help their loved one meet his/her goals.
Capability Test for: Mr. WXYZ Date: July 19, 2017
Ask and encourage the resident to do each of the following:
- Range of Motion (ROM)
- Full ROM to 180 degrees of abduction (hands over head) __1__ (1 point if yes, 0 if no.)
- Full external rotation (hands behind head) _1____ (1 point if yes, 0 if no)
- Full internal rotation and adduction (hands in small of back) __0__ (1 point if yes, 0 if no)
- Either lying or sitting, point and flex your toes, bend and straighten your knees, and/or if sitting, ask to march.
- Able to flex ankle__1__ (1 point if yes, 0 if no)
- Able to point toe__1___ (1 point if yes, 0 if no)
- Able to bend and straighten knees ___1___ (1 point if yes, 0 if no)
- Able to march ___1_(weak)_ (1 point if yes, 0 if no)
- Chair rise – observe to do this independently or how much help is needed (give up to 10 minutes to complete the task)
- How many tries does it take? __0_ (Scoring: 1-3 tries= 1 point; > 3 tries = 0 points)
- Do they use their arms? ___0___ (0 point if yes, 1 if no)
- Can they make it to a full stand and stand independently for 1 minute? ___0__
(1 point if yes, 0 if no)
- Follow a one, two, or three step commands doing a functional task:
Ask the participant to take a towel, fold it in half, and put it on the table (bedside table or bed or whatever is available).
- Follows a one-step verbal command __0____ (1point if yes, 0 if no)
- Follows a two-step verbal command ___0____(1point if yes, 0 if no)
- Follows a three-step verbal command ___0___ (1point if yes, 0 if no)
- Follows a one-step visual/cueing command ___1___ (1 point if yes, 0 if no)
- Follows a two-step visual/cueing command ___0___ (1point if yes, 0 if no)
- Follows a three-step visual/cueing command ___0___ (1 point if yes, 0 if no)
Total Score: 7 (max = 16)
HIGHER SCORES ARE BETTER CAPABILITY
Care Plan Snapshot
Resident Name: Mr. WXYZ
Room number: 0A
|Short term goal #1: Resident will attend at least one preferred activity each day to decrease boredom and restlessness
Short term goal #2: Resident will perform sit-to-stand exercises at least once daily with assistance from staff to increase strength, maintain ability to transfer, and decrease risk of falls
Short term goal #3: Resident will go outside at least once per day, weather permitting, with assistance from staff
Long-term goal: Resident will show an increase in expressions of wellbeing (smiling, laughing, engaging in activities) and a decrease in expressions of distress (agitation, restlessness, wandering and apathy).
|Care Area||Resident Responsibilities||Staff Responsibilities|
|Resident will self-propel in WC, perform sit-to-stand exercises with assistance daily, participate in at least one scheduled activity daily, visit outdoor courtyard once daily, and transfer out of WC and into chair for all meals with assistance
|Staff will encourage resident to self-propel in WC, assist with sit-to-stand exercises after lunch daily, encourage and assist resident to attend at least one daily activity with staff; visit outdoor patio with assistance from staff once daily, and assist with transfer out of WC for all meals|
|Bathing/Grooming||Resident will wash/dry face and upper body with visual cuing from staff
|Staff will provide 1-step visual cuing and encouragement for resident to wash/dry face and upper body|
|Dressing||Resident will dress upper body with visual cuing from staff and engage in AROM while getting dressed
e.g., wave to friend in the hallway, march knees up to hit GNA’s hands, swim strokes
|Staff will provide 1-step visual cuing to assist resident in dressing upper body; assist resident to perform AROM while dressing using 1-step visual cuing; ask resident to lift legs to help dress lower body|
|Eating||Resident will eat finger foods and use utensils as needed with visual cuing from staff
|Staff will place one food on plate/in bowl at a time, cut foods as needed and provide finger foods to encourage independence; use visual cuing with utensils|
|Oral Care||Resident will brush teeth twice each day with 1-step visual cuing from staff as needed
|Staff will have supplies ready and provide 1-step visual cueing and encouragement|
|Resident will assist with transfer to toilet
|Staff will encourage toileting after meals or at designated intervals; use 1-step cues during transfers; monitor for skin breakdown|
|Behavioral Issues: Restlessness, agitation; occasionally engages in disruptive vocalizations, apathetic
Related to: Schizophrenia; Alzheimer’s disease; difficulty adjusting to new surroundings
Approaches by staff:
(What are his interests, likes/dislikes, strengths? Who are his favorite caregivers?)
Mr. WXYZ loves to go outside and visit with his buddies. They like to talk about their time in the war. He also enjoys listening to jazz music, and it calms him down when he is agitated. His favorite GNA is Mary. He does not like eating in bed or playing games like BINGO, because they are for “old” people.