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.

 

Best practice: Fall risk reduction

Falling is an ever-present concern and challenge for nursing homes, and falls at home is often the reason why family members decide to move their loved one to a nursing facility. Too often, however, staff and residents’ fear of falling can lead to a vicious cycle:

  • An ambulatory resident falls and gets hurt.
  • The resident recovers physically, but may now be afraid to walk for fear of falling.
  • The staff also fear that the resident will fall again, so they continually tell the resident to “sit down so you don’t fall,” reinforcing the resident’s fear.
  • The resident then sits more and walks less (if at all), and consequently becomes weak (which is just one of the many negative effects of immobility).
  • One day, the resident tries to walk or transfer without assistance (common among people with dementia who forget they need help) and falls because he/she is now so weak.

…And the cycle begins again.

How do we break this cycle?

Tricks of the trade:

  1. Review with staff why people with cognitive decline (who may not be able to communicate their needs verbally) want to get up and walk on their own. Are they bored? Do they hurt from sitting for a long period of time? Do they need to use the bathroom? Do they forget they need help to walk?
  2. A supervised 5-minute walk could be enough to satisfy their need to move for a while, and may help decrease negative behaviors later on due to boredom or discomfort.
  3. Instead of saying, “Sit down, you might fall!”, try to get in the habit of saying something like, “I see you want to walk. Please wait and someone will help you very soon.” …then take the individual for a short walk/ a quick stand up for a moment or two / a hug and a dance…..
  4. Perform fun “sit to stand” exercises throughout the day with residents….put on some music, have them grab the rails along the hallway and do 5 minutes of sit to stands with them!
  5. Spread the love and encourage physical function…..ask the resident, “Could you stand up and give me a hug?” –The reward back is a big hug from you!

Going outside: Residents need fresh air and sunshine

We hope you all had a chance to spend at least a little time outside over the July 4th holiday. Did your residents?

Fresh air and sunshine can do wonders for people’s spirits, especially for people with dementia. Research has shown that when people can freely use outdoor areas, agitation and aggression reduce, independence is promoted, and memory recall is more likely to occur. An outdoor space or garden gives people the chance to be physically active, feel unrestrained, be more in touch with nature, socialize, and do meaningful activities (like plant flowers) that make them feel at home. It can also help maximize sleep duration for residents who have trouble sleeping through the night.

Find more information at:

https://www2.health.vic.gov.au/ageing-and-aged-care/dementia-friendly-environments/gardens-outdoors

And while indoor household tasks like folding laundry and sweeping floors can help engage residents in meaningful activity, this can work outside too! Have residents help sweep leaves and dirt off the deck or patio, pick up sticks, fill the bird feeder, and plant or water the flowers. There are lots of outdoor games too…horseshoes, beanbag toss, walking races, and beach ball volleyball to name a few.

What can you do this week to get more residents outside?

Increasing resident engagement in activities

We’ve talked about how encouraging residents to participate as much as possible in their own care can help maintain or even increase function and decrease negative behaviors. Let’s remember that residents with moderate to severe dementia can have fun too!

How often do we see a group of residents participating in a recreational activity, but notice that at least a few of them are left out? Sitting in the corner looking on? Often, these more “challenging” residents are the people who most need to be active and engaged in activity so they avoid feelings of frustration, agitation, and boredom.

To help with this, here are some activity ideas that your nurses, nursing assistants and recreation staff can use to get residents with cognitive decline in on the fun:

  • Flyswatter volleyball: Give residents plastic flyswatters have them hit a balloon back and forth to each other
  • Dance, dance, dance! Turn off those televisions and turn on some music and dance. Have staff members take turns playing music from their iPods through a speaker. Fast or slow, old or new, music has the power to move everyone.
  • Horseshoes: Now that summer is here, horseshoe games are everywhere. Look for the foam kind and play inside or outside on a patio. Residents can play while standing or sitting.
  • Foam swim noodles: Get a bunch of these, cut them in half, and start bending. These make for great resistance exercises! Leave them out in common areas for a safe, easy way to start spontaneous exercise.
  • Movement scarves: These can be found on enasco.com, or you can make your own with a lightweight material. Toss these colorful scarves in the air and have residents try to catch them. These scarves can be better than throwing a ball back and forth since people with slower reflexes and limited hand flexibility can catch them more easily.
  • Chores! Yes, chores. Your kids might not agree, but for older adults with dementia, doing familiar household chores can be calming and comforting. Grab a basket of cloth napkins and ask them to help you by folding them. Give them a broom and ask them to help you sweep the floor since company will be coming. Get some pillowcases or old clothes, hang a clothesline between a few walls, and give them some clothespins. They can hang the laundry.
  • Don’t forget to go outside! Warmer days are here now, so in the morning or early evenings when it’s a bit cooler, go outside. The sunshine, change of scenery and fresh air is something we all need. Look at the flowers, look for birds, and have some lemonade.