Care Plan for ADL Total Dependence

Category / Primary Body System

• General Care

Problem

• Resident is totally dependent on assistance for Activities of Daily Living (ADLs).

Goal

• Resident will receive comprehensive care to maintain skin integrity, hygiene, and safety for the next 90 days.

Plan/Approach

1. Skin Care and Protection

   • Apply lotion to all bony prominences and buttocks to prevent skin breakdown and provide protective skin care.

2. Call Bell Accessibility

   • Keep call bell within reach, encourage its use, and ensure it is answered promptly to address resident needs in a timely manner.

3. Regular Monitoring

   • Check frequently on the resident's needs to ensure all aspects of care are addressed, including comfort, hydration, and toileting.

4. Personal Hygiene and Grooming

   • Brush hair daily to maintain personal hygiene and grooming standards.
   • Ensure that clothes are clean, neat, and in good repair to promote dignity and comfort.

5. Safety Measures

   • Keep side rails up as ordered and desired to ensure safety and prevent falls.

Rationale

1. Skin Care and Protection

   • Applying lotion to bony prominences and buttocks helps prevent pressure ulcers and maintain skin integrity, which is crucial for residents with limited mobility.

2. Call Bell Accessibility

   • Keeping the call bell within reach and responding promptly ensures that the resident can communicate their needs and receive timely assistance.

3. Regular Monitoring

   • Frequent checks ensure that all needs are met promptly, reducing the risk of complications such as dehydration, constipation, or discomfort.

4. Personal Hygiene and Grooming

   • Maintaining personal hygiene and clean clothing enhances the resident’s dignity, comfort, and overall well-being.

5. Safety Measures

   • Using side rails as ordered helps prevent falls and ensures the resident’s safety in bed.

Actions

1. Skin Care and Protection

   • Apply lotion daily to bony prominences and buttocks, documenting the condition of the skin and any changes observed.

2. Call Bell Accessibility

   • Place the call bell within easy reach of the resident and check regularly to ensure it remains accessible.
   • Encourage the resident to use the call bell for any needs and ensure staff respond promptly to calls.

3. Regular Monitoring

   • Conduct frequent checks on the resident, documenting any needs addressed and changes in condition.
   • Provide assistance with hydration, toileting, and repositioning as needed.

4. Personal Hygiene and Grooming

   • Brush the resident’s hair daily, ensuring it is clean and tidy.
   • Inspect and change clothing daily, ensuring it is clean, neat, and in good repair.

5. Safety Measures

   • Keep side rails up as ordered and desired by the resident, ensuring they are properly positioned and secure.