Patient: DOB: SS#:
Aides name: Aide ID#:
Diagnosis:
Mental status: Oriented to: Person Place Time Forgetful at times
Patient and Caregiver Education:
Healthy and happy at home: ABC's reporting ABC's prevention
Cards Given: Patient Aide
1. A-Pleasurable activities (for psychosocial wellbeing) Outdoor Activities Beauty/pampering Crafts/games Socializing Other pleasurable activities
2. B-Deep breathing- 5 times twice a day Patient educated on Incentive Spirometer use and frequency Aide educated on Incentive Spirometer use and frequency Incentive spirometry measure
3. C-Circulation and skin Increase movement Use moisturizer
4. D- Diet (enough water and healthy food) Regular Diabetic Low cholesterol Low fat diet Low salt diet Fluid restrictions: ml/24hrs Daily weights N/A Education-Choosemyplate.gov
6. E-Elimination/Bathroom: 3-4 hr toileting while awake Remind Assist 7. F-Falls and Feeling Pain Mobility Devise(s) No Yes: Cane Walker Wheelchair TUG test score >12 seconds, supervisor notified Patient educated on TUG use and frequency Aide educated on TUG use and frequency Mobility Safety measures/Precautions: Keep pathways clear Use of assistive devises Fall precautions, slow position change, safety in ADL’s Active Range of Motion: Chair Standing Mobile Pain- Pleasurable activities for pain reduction 8. G-Go take your medications Medication and timing review (morning, noon, evening, bedtime, as requested) Medication box: No Yes
Coordination calls for reporting Aide POC completed Aide Supervision completed HIE consent form completed, or prior consent Progress Note: Follow plan of care and notify coordinator of any changes in health, questions or concerns
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