Care Plan for Long Term Care Adjustment

Category / Primary Body System

• Psychosocial and Mental Health

Problem

• Patient is at risk for maladjustment due to placement in the facility for long-term care.

Goal

• Patient will adjust to the facility, as evidenced by participating in care daily for 90 days.

Plan/Approach

1. Emotional and Psychological Support

   • Encourage verbalization of feelings regarding long-term care placement as needed.
   • Encourage family visitation as appropriate to provide emotional support.

2. Social Services and Therapy

   • Arrange social service consults as needed to address psychosocial needs and provide support.
   • Arrange PT/OT evaluations and treatments as needed to support physical functioning and enhance adjustment.

3. Activity and Engagement

   • Encourage participation in diversional activities to promote socialization and engagement.
   • Provide a variety of activities to cater to the patient's interests and preferences.

4. Medication Management

   • Administer medications as ordered to manage any underlying medical or psychological conditions.

5. Monitoring and Communication

   • Notify MD/RNP of any changes in the patient's medical condition.
   • Monitor the patient's adjustment and engagement in care, documenting progress and any issues.

Rationale

1. Emotional and Psychological Support

   • Verbalizing feelings helps the patient process emotions related to the transition and reduces feelings of isolation.
   • Family visits provide comfort, familiarity, and a sense of continuity, aiding in adjustment.

2. Social Services and Therapy

   • Social service consults provide resources and support for coping with the transition.
   • PT/OT helps maintain physical function, contributing to a sense of independence and well-being.

3. Activity and Engagement

   • Diversional activities provide mental stimulation, social interaction, and a sense of purpose.
   • Offering activities that align with the patient's interests helps them feel more at home in the facility.

4. Medication Management

   • Proper medication management ensures that the patient's health conditions are controlled, contributing to overall stability.

5. Monitoring and Communication

   • Monitoring and timely communication with the healthcare team ensure that any issues are addressed promptly, promoting a smooth adjustment.

Actions

1. Emotional and Psychological Support

   • Encourage the patient to express feelings about the transition to long-term care, providing active listening and validation.
   • Facilitate family visits and support family involvement in the patient's care.

2. Social Services and Therapy

   • Schedule social service consults to address any psychosocial issues and provide ongoing support.
   • Arrange PT/OT evaluations and treatments to address physical needs and promote independence.

3. Activity and Engagement

   • Offer a variety of activities and encourage the patient to participate in those that interest them.
   • Document the patient's participation in activities and any preferences or feedback.

4. Medication Management

   • Administer medications as prescribed, monitoring for effectiveness and any side effects.
   • Review medications regularly with the healthcare team to ensure optimal management.

5. Monitoring and Communication

   • Monitor the patient's adjustment, noting any changes in mood, behavior, or participation in care.
   • Report any significant changes in the patient's condition to the MD/RNP promptly.