Table of Contents
PRINCIPLES AND STANDARDS OF CARE PLANNING
Introduction 1
Care Plan Basics 2
Components of the Care Plan 4
Individualizing the Care Plan 7
The Care Plan Conference 8
Care Conference Notes 10
Consistency of Documentation and Care 11
Nursing Assistant Care Form 12
CARE PLAN TEMPLATES
Care plans are in alphabetical order.
Blank Care Plan
Abusive, Physically
Abusive, Verbally
Activities, Dependent on Staff
Airway Clearance, Ineffective
Allergies
Allergies, Food
Anemia
Anger
Angina
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
Discharge Pending
Fall Risk
Family, Coping Ineffective
Fluid Volume Deficit
Fluid Volume Excess
Gastrointestinal Discomfort
Grief over Lost Status, Roles
Hoards Objects
Hypertension
Hypotension
Hypothyroidism
Incontinence, Bowels
Incontinence, Functional Urinary
Incontinence, Stress Urinary
Incontinence, Urge Urinary
Knowledge Deficit
Manipulative Behaviors
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
Rejects 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, Pressure Ulcer
Skin Breakdown, Unstageable Ulcer
Skin Breakdown, Other Ulcers or Wounds
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
Medication Care Plans
Care plans are in alphabetical order.
ACE Inhibitor
Acetaminophen
Allergy, Cough, Cold Medication
Alpha Blocker
Antiarrhythmic
Antibiotic
Anticholesterol
Anticoagulant
Anticonvulsant
Antidepressant
Antidiabetic
Antihypertensive
Antiparkinsonian
Barbiturate
Beta Blocker
Calcium Channel Blocker
Digoxin
Fluoroquinolone
Glucocorticoid
Hematinic
Hypnotic
Iron
Lithium
MAO Inhibitor
Muscle Relaxant
Nitrate
NSAID
Opioid
Pain Medication
Phenothiazine
Platelet Inhibitor
Polypharmacy
Proton Pump Inhibitor
Psychotropic
Respiratory Medication
Self-Administration
Tricyclic Antidepressant
Urinary Incontinence Medication
Vancomycin
References