CNSW Care Plan

CNSW Care Plan Template
PROBLEM INTERVENTION OUTCOME

Decreased functional level due Provide information regarding Patient’s level of functioning
to onset of renal disease or importance of rehabilitative improves (as demonstrated by
other medical complication activities functional status measure, i.e.
Encourage patient to pursue Karnofsky or PCS of SF-36)
hobbies/activities he/she Patient resumes
enjoyed prior to onset of renal hobbies/activities he/she
disease enjoyed prior to onset of renal
Encourage patient to disease
exercise within his/her Patient begins exercise
functional limitations program
Refer to Vocational Patient pursues Voc Rehab
Rehabilitation Office to pursue referral
job training
Compromised ability to care Refer to community Patient is adequately cared for
for self or perform activities of resources for in-home help or at home with assistance from
daily living (ADL) home-delivered meals community resources
Need for non-medical Refer to community home Patient is receiving
support (companion, meals, health service adequate medical care in the
chore services, etc) Refer to durable medical home
Need for home health care equipment company Patient is able to function
Need for durable medical Locate appropriate medical independently at home with
equipment or residential facility for patient durable medical equipment
Need for placement and assist patient/family in Patient is receiving
Need for structured day making transition from home to adequate care in new medical or
activities facility residential facility
Other needs for care Locate and refer to Patient is receiving
community day care or adequate care and stimulation
sheltered workshop program during day time hours
Environmental Problems Provide referrals, educate on Patient has adequate
Income needs use of resources, assist in environmental resources to
Medical insurance needs accessing resources, provide adhere to treatment plan
Housing needs advocacy efforts Patient has adequate
Nutritional needs Refer to disability or other financial income to meet
Transportation needs entitlement programs needs
Medication needs Refer to Medicare, Patient has adequate
Recreation/leisure needs Medicaid or other insurance medical insurance to adhere to
programs treatment plan
Refer to community Patient has adequate
housing or homeless shelter housing
programs Patient is adequately
Refer to community food nourished
banks or dietitian for food Patient is able to get to
supplements and from dialysis and other
Refer to non-emergency medical appointments
medical or public ADA Patient has medications
transportation service which have been prescribed
Refer to pharmaceutical Patient is able to pursue
indigent-patient programs or recreation/leisure plans thus
other medication assistance improving quality of life
program
Provide information
and/or assistance regarding
making travel or other
recreational arrangements
Lack of knowledge Provide education Patient/family understands
Patient/family needs Provide information on treatment plan
information on peritoneal or peritoneal and/or hemodialysis Patient/family verbalizes
hemodialysis Provide information on understanding of peritoneal
Patient/family needs transplantation and/or hemodialysis
information on transplantation Provide information on Patient/family verbalizes
Patient/family needs Advance Directives or other understanding of
information on Advance end-of-life issues transplantation
Directives or other end-of-life Provide information or Patient/family verbalizes
issues refer to appropriate resource understanding of Advance
Patient/family needs person Directives and/or other end-of-
information on medical life issuesPatient/family
insurance and/or coordination verbalizes understanding of
of medical insurance benefits medical insurance or
coordination of medical
insurance benefits
program
Provide information
insurance benefits
program
Provide information
insurance benefits
Lack of understanding – Provide education in other Patient/family verbalizes
barriers prevent patient/family mediums understanding of treatment plan
from understanding treatment Remove barriers to Patient/family verbalizes to
plan patient/family understanding of interpreter understanding of
Language barrier prevents treatment plan treatment plan
patient/family from Obtain services of interpreter Patient/family verbalizes
understanding Educate bilingual family understanding of treatment plan
Literacy barrier prevents member or friend Patient/family demonstrates
patient or family from Use audiovisual resources to understanding of treatment plan
understanding educate patient/family Patient/family demonstrates
Vision barrier prevents Use audio resources to educate understanding of treatment plan
patient or family from patient/family
understanding Use written materials to educate
Hearing barrier prevents patient
patient or family from Use materials geared to
understanding appropriate educational level to
Learning disability teach patient/family about
prevents patient or family from treatment plan
understanding
Lack of adherence to treatment Remove barriers to treatment Patient demonstrates better
plan adherence adherence to treatment plan
Cultural or religious beliefs Modify treatment plan and Patient demonstrates better
interfere with adherence to involve patient in goal-setting adherence to treatment plan
treatment Provide mediation to Patient demonstrates better
Poor relationship with improve relationship between adherence to treatment plan
health care team impedes patient and health care team
adherence to treatment plan Provide referral and
Impaired adjustment to counseling to improve patient’s
chronic renal disease interferes adjustment to disease and
with adherence to treatment treatment plan
plan
Impaired adjustment to Provide counseling and referral Patient demonstrates increased
treatment services to enhance adjustment ability to cope with disease and
Depression/anxiety to treatment treatment
Family/marital problems Provide individual or group Patient demonstrates
related to chronic disease and counseling to patient in dialysis decreased symptoms of
treatment clinic depression/anxiety
Substance abuse Refer patient to psychiatrist to Patient shows improved
Sexual problems assess need for psychotropic score on instrument measuring
medication extent of depression
Provide counseling to Patient/family verbalizes
patient/partner in the dialysis reduced problems at home
clinic Patient scores higher on
Refer patient/family to instrument measuring quality of
community counseling services life
Provide counseling to patient in Patient enters and adheres
dialysis clinic to alcohol/drug treatment
Refer to alcohol or drug program
treatment program Patient verbalizes
Provide counseling to improvement in sexual
patient/family in the dialysis functioning
clinic
Refer to MD to rule out
physiological etiology or to
assess for medication needs
Provide counseling to
patient/partner in clinic
Relationship/social network Provide counseling, referral Patient/family verbalize
problems and mediation to resolve reduction in problems
Inadequate social support problems Patient verbalizes feeling less
system causing patient to feel Provide supportive isolated
isolated and alone counseling in the dialysis clinic Patient participates in
Family/marital problems Refer to services within the supportive community
not related to chronic disease community such as support programs
and treatment groups, senior centers, etc. Patient scores higher on
Maltreatment (child, adult, Provide counseling to instrument measuring perceived
elderly) patient/partner in the dialysis social support
Conflictual relationship clinic Patient/family reports
with health care team Refer patient/family to reduced problems at home
community counseling services Patient and family living in
Refer to protective services safe environment. No evidence
Provide mediation services of abuse noted in dialysis clinic.
to improve patient/family Relationship between staff,
relationship with health care patient and family noted to be
team less conflictual
Psychiatric problems not Provide counseling to patient in Patient demonstrates increased
related to impaired adjustment dialysis clinic ability to cope with psychiatric
to treatment Refer to counseling resources in problems
the community
Pre-existing psychiatric Provide counseling to family Family demonstrates less stress
disorder regarding caregiver role and related to caring for patient
Organic brain disorder responsibilities Family demonstrates less stress
Mental retardation Provide referral to community related to caring for patient
resources
Provide counseling to family
regarding caregiver role and
responsibilities
Provide referral to community
resources

CNSW Care Plan

Caricato da

Informazioni sul documento

Descrizione originale:

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

CNSW Care Plan

Caricato da

Copyright:

Formati disponibili

CNSW Care Plan Template

PROBLEM INTERVENTION OUTCOME

Potrebbero piacerti anche