Updated Care Plan for Assistance with Activities of Daily Living (ADLs)

Category / Primary Body System:

Functional Mobility / Musculoskeletal System

Problem:

The patient is unable to perform ADLs independently.

Goal:

The patient will continue to participate in ADLs daily for 90 days.

Plan/Approach:

1. ADL Assistance:

   • Step: Assist the patient with bathing, grooming, and dressing.
   • Rationale: Providing assistance with personal hygiene and dressing promotes the patient’s dignity and well-being.
   • Actions: Help the patient with bathing, brushing teeth, combing hair, and dressing. Use adaptive equipment as needed to facilitate independence.

2. Call Light Accessibility:

   • Step: Ensure the call light is within the patient’s reach.
   • Rationale: Accessible call lights allow the patient to easily request assistance, ensuring safety and timely help.
   • Actions: Position the call light within the patient’s reach and remind them to use it when needed.

3. Incontinent Care:

   • Step: Provide incontinent care as needed.
   • Rationale: Timely and proper incontinent care prevents skin breakdown and maintains the patient’s comfort and dignity.
   • Actions: Check and change incontinence products regularly, clean the skin gently, and apply barrier creams as necessary.

4. PT/OT Evaluation:

   • Step: Arrange for physical therapy (PT) and occupational therapy (OT) evaluation and treatment as needed.
   • Rationale: PT and OT interventions enhance the patient’s functional abilities and promote independence.
   • Actions: Schedule PT and OT sessions, follow the therapists’ recommendations, and integrate exercises and techniques into daily care.

5. Transfer Assistance:

   • Step: Assist with all transfers as needed.
   • Rationale: Safe transfer techniques prevent falls and injuries for both the patient and staff.
   • Actions: Use proper body mechanics and transfer aids (e.g., gait belts, slide boards) to assist the patient with transfers. Ensure the patient feels secure during transfers.

6. Repositioning:

   • Step: Turn and reposition the patient per house protocol and as needed.
   • Rationale: Regular repositioning prevents pressure ulcers and promotes circulation.
   • Actions: Reposition the patient at least every two hours, use pillows and positioning devices to support proper alignment, and monitor for signs of pressure sores.

7. Skin Integrity Monitoring:

   • Step: Monitor the patient’s skin integrity every shift during care.
   • Rationale: Early detection of skin issues prevents complications and ensures prompt treatment.
   • Actions: Inspect the skin for redness, sores, or breakdown during each care routine, document findings, and report any concerns to the healthcare provider.

8. Meal Assistance:

   • Step: Assist the patient during meals.
   • Rationale: Providing meal assistance ensures the patient receives adequate nutrition and hydration.
   • Actions: Help the patient with setting up the meal, feeding if necessary, and encouraging independence with adaptive utensils. Monitor food and fluid intake.

9. Mobility Assistance:

   • Step: Assist the patient with mobility.
   • Rationale: Supporting mobility helps maintain the patient’s strength and prevents complications associated with immobility.
   • Actions: Encourage and assist the patient with walking, using mobility aids as needed. Follow the PT’s recommendations for exercises and activities.