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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