Care Plan for Maintaining Independence in Activities of Daily Living (ADLs)

Category / Primary Body System

• General Care

Problem

• Resident is independent with activities of daily living (ADLs) but needs staff monitoring.

Goal

• Resident will maintain current ADL function without decline for the next 90 days.

Plan/Approach

1. Set-Up and Assistance

   • Set resident up for ADLs as needed twice daily (BID) to ensure they have all necessary supplies and support.

2. Monitoring and Support

   • Monitor for episodes of acute illness or weakness and provide extra assistance as necessary to prevent any decline in function.
   • Encourage the resident to report any decline in ability to facilitate timely intervention.
   • Offer PT/OT assessments for any noted declines in ADL function to provide specialized support and interventions.

3. Supplies and Hygiene

   • Provide supplies as needed (soaps, lotion, etc.) and monitor to ensure they are resupplied as necessary.
   • Encourage complete personal care, providing reminders for mouth care, brushing hair, peri-care, lotion application, positional changes, active mobility, rest as needed, and nail care.

4. Bathing and Grooming

   • Ensure the resident has a full body bath or shower at least once a week, and as needed or desired.
   • Ensure that clothes are clean and in good repair to maintain dignity and comfort.

5. Specialized Services

   • Provide PRN services, including dental, podiatry, audiology, and hairdresser as needed to maintain overall health and hygiene.
   • Nail care by resident, CNA, nurses, or beauty shop as appropriate.

6. Privacy and Dignity

   • Check frequently on needs, but ensure it is not intrusive to respect the resident’s independence and privacy.
   • Keep the call bell within reach, encourage its use, and answer promptly to ensure the resident can easily communicate their needs.
   • Provide privacy by always knocking and waiting for a response before entering the resident’s room.

Rationale

1. Set-Up and Assistance

   • Providing set-up and assistance twice daily ensures the resident has what they need to complete ADLs independently, promoting self-sufficiency and preventing unnecessary decline.

2. Monitoring and Support

   • Monitoring for acute illness or weakness and encouraging reporting of any decline allows for timely intervention and support, preventing further decline.

3. Supplies and Hygiene

   • Ensuring the resident has necessary supplies and encouraging complete personal care maintains hygiene, comfort, and health.

4. Bathing and Grooming

   • Regular bathing and ensuring clothes are clean and in good repair maintain hygiene, dignity, and comfort.

5. Specialized Services

   • Providing specialized services as needed ensures comprehensive care, addressing all aspects of the resident’s health and well-being.

6. Privacy and Dignity

   • Frequent checks that are not intrusive, keeping the call bell within reach, and ensuring privacy respect the resident’s independence and dignity.

Actions

1. Set-Up and Assistance

   • Assist the resident with ADL set-up twice daily, ensuring they have all necessary supplies and support.

2. Monitoring and Support

   • Monitor for signs of acute illness or weakness, providing additional assistance as needed.
   • Encourage the resident to report any declines in ability and document any changes.
   • Facilitate PT/OT assessments for any noted declines to provide specialized interventions.

3. Supplies and Hygiene

   • Ensure the resident has all necessary personal care supplies and monitor for the need to resupply.
   • Provide reminders for personal care tasks, ensuring they are completed regularly.

4. Bathing and Grooming

   • Schedule and assist with a full body bath or shower weekly, and as needed or desired.
   • Ensure the resident’s clothes are clean and in good repair, assisting as needed.

5. Specialized Services

   • Coordinate PRN services such as dental, podiatry, audiology, and hairdressing appointments.
   • Provide or supervise nail care as appropriate, ensuring it is done regularly.

6. Privacy and Dignity

   • Check on the resident’s needs frequently, ensuring not to be intrusive.
   • Place the call bell within easy reach and respond promptly to any calls.
   • Respect the resident’s privacy by knocking and waiting for a response before entering their room.