Table of Contents
PRINCIPLES AND STANDARDS OF CARE PLANNING
Introduction 1
Care Plan Basics 2
Components of a Care Plan 5
The Care Plan Conference 9
Care Conference Notes 11
Consistency of Documentation 12
Nursing Assistant Care Form 13
CARE PLAN TEMPLATES
Blank Care Plan
Abusive, Physically
Abusive, Verbally
Activities, Dependent on Staff
Airway Clearance, Ineffective
Allergies
Allergies, Food
Anemia
Anger
Angina
Anticoagulant Therapy
Anxiety
Blepharitis
Blood Sugars, Unstable
Breathing Patterns, Ineffective
Cardiac Output, Decreased
Cataracts
Chewing Problem
Cognitive Deficit, Decision-Making Impaired
Cognitive Deficit, Disordered Thinking
Cognitive Deficit, Memory Problem
Colostomy / Ileostomy
Communication, Hearing Impaired
Communication, Speech Impaired
Conflict with Family / Friends
Conflict with Staff
Constipation, Chronic
Dental Care
Depression
Diarrhea, Chronic
Fall Risk
Family, Coping Ineffective
Fear
Fluid Volume Deficit
Fluid Volume Excess
Gastrointestinal Discomfort
Grief Over Lost Status, Roles
Gum Problems
Hoards Objects
Hypertension
Hypotension
Hypothyroidism
Incontinence, Bowels
Incontinence, Functional Urinary
Incontinence, Stress Urinary
Incontinence, Urge Urinary
Knowledge Deficit
Knowledge Deficit, Fall Risk
Knowledge Deficit, Pain Care
Knowledge Deficit, Restraints
Manipulative Behaviors
Medication, High Number
Medication, Pain
Medication, Psychotropic
Medication, Self-administration
Non-compliance
Obesity
Pacemaker
Pain
Pain, Cognitively Impaired
Paranoia
Parkinson’s Disease
Peripheral Artery Disease
Peripheral Vascular Disease
Physical Mobility, Ambulation
Physical Mobility, Bed Mobility
Physical Mobility, Locomotion
Physical Mobility, Range of Motion
Physical Mobility, Transfers
Prefers Own Routine
Refuses to Eat / Drink
Resists Care
Restraint
Rheumatoid Arthritis
Seizures
Self Care Deficit, Bathing
Self Care Deficit, Dressing and Grooming
Self Care Deficit, Eating
Self Care Deficit, Hygiene
Sensory Deprivation
Sensory Perception, Altered
Skin Breakdown
Skin, Fragile
Sleep Pattern Disturbance
Smoking
Social Isolation
Socially Inappropriate Behavior
Strengths
Swallowing Problem
Terminal Prognosis
Tracheostomy
Tube Feeding
Unhappy with Roommate / Other Resident
Urinary Retention / Urinary Catheter
Urinary Tract Infection, Potential
Visual Impairment
Wandering
Weight Loss
Withdrawal from Care / Activities
SOURCE DOCUMENTS, REFERENCES, INDEX
Standards of Clinical Nursing Practice i
Excerpts from the Code of Federal Regulations iii
Excerpts from the RAI MDS 2.0 Users Manual vi
References vii
Cross-Referenced Index ix