Sample Care Plan

PROBLEM GOAL APPROACH DISCIPLINE

Edema

Resident will not develop increased edema
  1. Assess amount of edema to extremity daily and document.
  2. Keep extremity elevated all times except during ambulation
  3. Assess site for weeping and pitting
  4. Report any redness, heat or rash accompanying edema to the physician.
  5. Follow dietary guidelines, i.e.: fluid restrictions; low sodium diet as ordered.
  6. Wrap weeping extremities with gauze and cotton absorbent terry socks to prevent the resident from slipping on dripping fluids and change as needed.
  7. Provide education on the resident's medical condition.
  8. Remove any obstructions on the floor of the resident's room.
  9. Maintain clear path in front of the resident at all times during ambulation.
  10. Administer cardiac medication and/or diuretic as ordered by the physician.
  11. Review lab work ordered by the physician.
  12. Remind the resident to wear nonskid or rubber-soled shoes or slippers at all times every shift.
  13. Encourage the resident to ask for assistance to transfer from bed to wheelchair or any other surface.
  14. Keep all personal items within the resident's reach at the bedside table at all times.
  15. Assess for signs and symptoms of a rash on the weeping extremity site.
  1. N
  2. A,N
  3. N
  4. N
  5. ALL
  6. N
  7. N
  8. ALL
  9. ALL
  10. N
  11. N
  12. N
  13. N
  14. N
  15. N