|
|
| Name (last, first) | Diagnosis | ||||||||
| Address | |||||||||
| ZIP SS# - - | |||||||||
| Personal | take temperature | sponge bath by sink | S | M | T | W | TH | F | S |
| Care | bed bath | shower | |||||||
| Regimen | tub bath | shampoo | |||||||
| groom hair | denture care | ||||||||
| mouth care | foot care | ||||||||
| nail care | other: | ||||||||
| special skin care: | |||||||||
| bed sore care: A. | |||||||||
| B. | |||||||||
| C. | |||||||||
| D. | |||||||||
| special tube care: | |||||||||
| dressing assistance | assist with medicine | ||||||||
| daily weight - record on calendar | crush all pills | ||||||||
| urine catheter. empty drainage bag | other: | ||||||||
| special bowel regimen | note BM at right | ||||||||
| Dietary | meal planning & preparation | diet: | |||||||
| Functions | feed: complete assist/partial assist | note appetite at right | |||||||
| trouble swallowing | puree food | ||||||||
| Activity | assist with walking | cane | |||||||
| assist transfer sitting to standing | walker | ||||||||
| assist transfer bed to chair | don artificial limb: | ||||||||
| Bed exercises - turn every 1- 2 hrs | crutches | ||||||||
| range of motion to limbs every 4 hrs | hoyer lift | ||||||||
| Special Therapies to follow (written plan): | physical therapy | ||||||||
| speech therapy | |||||||||
| occupational therapy | |||||||||
| other: | |||||||||
| Household | change linens | make bed | |||||||
| light cleaning | errands | ||||||||
| essential laundry | marketing | ||||||||
| Additional Instructions: | |||||||||
Facts
|
Shortcut to Healthy Hearts
|
Annual Physical
|
Blood Pressure
|
Blood Pressure Log
|
Blood Pressure Monitoring
|
Taking Medicines Safely
|
Medicines Record
|
Menopause
|
Caregiver Support
|
Care Plan
|
Child Development Checklist
|
Safety Checklist for
Infants and Toddlers
|
Improve Doctor–Patient Communication
|
Path for a Healthy Heart
|
Taking Coumadin
|
Get Smart About Smoking
|
How to Quit Smoking
|
Heart Wellness
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