Fundamentals of Nursing and Midwifery 2e

Chapter 17 Planning person-centred care

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PATIENT NAME: MRN: DOB: Date: Date:

Date: am pm nd am pm nd am pm nd

Investigations Mental status

Alert Orientated

Drowsy

CAM score

Confused

required if not

Unconscious

alert and orientated

Resistive to care, aggressive or agitated Complete CAM score, record in the box

Assessment

Frequency

Day 1

Day 2

Day 3

TPR & BP GMR SpO 2 CIWA-AR GCS U/A Other Daily weigh (record kg daily) in the box Mobility activity Identify level of assistance required for transfers (Refer to Mobility Status chart)

Record falls risk score daily & PRN Record postural BP if not attended O/A

Nutrition, NBM hydration & IV therapy: ensure cannula removed

Resite due:

IV therapy

Cannula score Special/normal diet Red or Blue alert Ensure diet flip chart correct Fluid restriction Circle NG /PEG/TPN rate Record Norton score once daily in square Pressure area sticker in AM shift report Pressure area care required:

Skin integrity

Hygiene / ADL’s Independent Full sponge Refer to Assist sponge mobility chart

Full shower chair Assist shower

Full bath with trolley bath Mouth & eye care required

Elimination

Patient continent Patient incontinent Urine Patient incontinent Faeces Chart bowels daily (each shift) on stool chart

Communication Speech Normal Slurred Dysphasic Aphasic

Assist with communication aids if speech difficulties present

Education Commence education for patients & carers Discharge planning Advise person/family of discharge destination

& approx date, commence interagency forms/ planning for home adjustments as needed/ planning for transport home

2 rate & device:

Special needs & technical activities

O

TPR (temperature, pulse, respirations), BP (blood pressure), GMR (glucometer reading), SpO 2 (oxygen saturation), CIWA-AR (alcohol withdrawal scale), GCS (Glasgow Coma Scale), U/A (urinalysis), NG (nasogastric), PEG (percutaneous endoscopic gastrostomy), TPN (total parenteral nutrition). See Appendix C for a list of abbreviations commonly used in healthcare facilities. Figure 17-3 Example of a care map