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