Complete Care Plans Book

 

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

Activity Intolerance

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