Care plan snapshots: Making care plans useful

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.

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Capability Test for: Mr. WXYZ                                                     Date: July 19, 2017

Ask and encourage the resident to do each of the following:

  1. 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)
  1. 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)
  1. 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)

  1. 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

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Care Plan Snapshot

Resident Name: Mr. WXYZ
Room number:  0A

 

Care Goals

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
Physical

Activity/

Ambulation

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
Toileting

 

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:

  • Assess for boredom, pain or other behavioral and psychological symptoms of dementia
  • Engage resident in sit-to-stand exercises, visits outside and other physical activities regularly
  • Provide consistency in care using same caregivers when possible; communicate successful strategies with other caregivers
  • When resident shows signs of boredom or agitation, attempt to engage him in one of his favorite activities, e.g., a game of horseshoes, going outside to courtyard, visit with receptionist
  • Respond calmly to resident during times of agitation, allow resident to vent feelings, and provide ample time for resident to respond to simple questions and direction from staff
  • Model behavior for resident
  • Offer choices to resident when available
 

Motivational ideas/Rewards:

 

(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.

 

Engaging residents with apathy

A person who is withdrawn or apathetic is someone who is socially withdrawn and is experiencing a loss of interest and motivation. Behaviors that reflect being withdrawn or apathetic might include:

  • sitting alone in one’s room
  • avoiding contact with others
  • making limited eye contact with others.

It’s important to note that these behaviors are not often considered problematic because they don’t call attention to themselves like screaming does. They can, however, lead to rapid loss of cognitive and physical function.

How to approach the person who is withdrawn or apathetic:
  • Try to engage the person in creative activities.
  • Give instructions slowly and break tasks down into manageable portions for the person.
  • Remain positive and calm with the person.
  • Encourage the person to do what they can for themselves and provide praise often.
  • Avoid excess stimulation such as large crowds or loud noises.

Things to try:

  • Sensory stimulation may be helpful. Some ways to do this might include playing music, looking through visually stimulating thing such as pictures from old calendars or holiday cards, and touching or holding a stuffed animal.
  • Involving the person in cooking or baking activities can help stimulate the sense of smell and be a good time to talk and reminisce with the person as their memory allows.
  • Consider the persons’ preferences. For example, if the person is fond of animals, bring in a therapy dog as a way to spark interest and movement (reaching, petting).
  • A visit from young children can be a wonderful, heartwarming way to engage a withdrawn older adult.
  • For many, a short walk or simply sitting outdoors for a short period of time can offer valuable sensory stimulation.
  • Try to engage the person in a 1:1 or small group social activity.  Try to individualize social contact, which can include casual conversations or “small talk.” Adapt the conversation based on how advanced the person’s dementia is. For someone with very advance dementia try to focus mostly on questions involving “here and now” discussion such as comments about music playing, food being served or the weather. For an individual with mild to moderate dementia, small talk can be facilitated by asking the person simple questions, such as: “did you ever play football in school?” or “have you always lived in Wisconsin?”
  • Talk to family members to learn more about the person’s history and use this information to plan activities. For example, a painter could help make posters for events; a policeman could “walk the beat”; a homemaker could help knead dough, dust or sweep the floors.
  • Another simple strategy for facilitating social contact is to share information about your life or plans for the day and ask the person with dementia for their input about things you share using straightforward questions.

Educating family members on person-centered care

Educating family members of your residents about your efforts to reduce the behavioral and psychological symptoms of dementia through person-centered behavioral approaches is critical. Family members can support staff and be a useful resource when determining what may motivate a resident to participate in his/her own care and engage in activity, and thereby decrease agitation, apathy and resistiveness to care.

One of the ways you can educate family members is by including information in your facility’s newsletter or other regular mailing or email to your residents’ loved ones. Below is a pre-written piece to help get you started:

Research repeatedly shows that older adults can improve their physical and mental health, slow cognitive decline, and increase their ability to participate in personal care needs like bathing and dressing by engaging in regular physical activity. Physical activity can also help decrease symptoms of dementia such as agitation, aggression, resistiveness to care and depression. Even short spurts of 10 minutes of activity can result in significant physical and emotional benefits. Being able to care for oneself as much as possible also helps preserve the dignity and independence that we all hope for as we age.

With this in mind, our staff will be working with your loved one to participate as much as possible in personal care activities and to engage in physical activities such as walking or self-propelling in their wheelchair to the dining room or doing some stretching and strengthening exercises while waiting for meals. You can help too. Go for a walk with your loved one when you visit, or ask a staff member to show you some exercises you can do with them while you visit. Ask their caregiver what activity goals they have for them and encourage your loved one as they try to reach their goals. Finally, support your family member’s caregivers as they use their knowledge and skills to involve your loved one in their care and other activities in order to transform expressions of distress into expression of well-being—a goal we all share.

Feel free to contact us if you have any questions about working with family as we move forward.