Big Book of Care Plans, Second Edition

Includes sections on restorative care, pain, and medications

The Big Book of Care Plans, Second Edition contains more than 100 modifiable resident-centered care plans. It breaks down the process and explains how the MDS 2.0 and Resident Assessment Protocols drive care planning. The tools and sample care plans inside encourage your team to write problems, goals, and interventions to promote a user-friendly plan of care and, ultimately, reflect the care given to the resident.

Much more than a compilation of sample care plans, The Big Book of Care Plans, Second Edition provides a comprehensive system to streamline your care planning process. This quick-reference care planning encyclopedia illustrates how staff members can work together to develop a resident-centered care plan.

What’s in the second edition?

• Sections devoted to care planning for restorative care, pain, and medications
• Area-specific evaluation forms
• Insight into high-risk areas for negative resident outcomes

The Table of Contents:

Section 1: The Practice of Care Planning
Care Plans, Then and Now
Medications and Care Planning
Assessment Questions Regarding Psychoactive Medications and Behavior
Treatment Principles for Behavior Management
Critical Questions When Using Behavior and Psychoactive Medication
Critical Questions When Using Depression and Psychoactive Medication
Beers Criteria
Pain and Care Planning
What to Consider When Care Planning
Assessment Questions for Personalized Care Planning and Pain

Section 2: Restorative Nursing Care Planning
Introduction to Restorative Care Planning
Restorative Nursing Care Plan Program
Potential Restorative Nursing Programs
Documentation Requirements and Recommendations
Documentation Tools
ADL RAP Decision Tree
Range of Motion Decision Tree

Combination Assessment and Care Plan Combination:
Bathing/Grooming
Dressing
Eating/Swallowing
Range of Motion: All Areas
Bed Mobility
Transfer
Walking
Wheelchair Mobility
Splint/Brace

Area Specific Evaluation Forms:
Grooming
Feeding
Transfer/Ambulation
Urinary Incontinence
Urinary Incontinence Pattern Tracking
Urinary Incontinence Care Plan
Combination Care Plan, Delivery Record, Progress Note
Delivery Records
Progress Notes

Section 3: MDS 2.0 Clinical Pathways
MDS 2.0 Clinical Pathways: Introduction
Non-Medicare Admission Assessment Procedure
Assessment Pathway: Admission Assessment and Care Plan
Pathway: Quarterly and Significant Change Assessment and Care Plan
Annual Assessment Procedure
Medicare PPS Assessment
Medicare PPS Policy and Procedure
14-Day Assessment: Open MDS 2.0 on ARD
30-, 60-, 90-Day Open MDS 2.0 on ARD
MDS 2.0 Admission Assessment Pathway: All Residents
MDS 2.0 Quarterly, Significant Change, and Annual Assessment Pathway
MDS 2.0 Medicare 14-, 30-, 60-, and 90-day assessment pathway
MDS 2.0 and Care Conference Schedule

Section 4: Understanding and Documenting RAPs, Clinical Assessments, and Care Conferences
Introduction to Successful Care Planning
The RAPs
Assignment Assessments
Pre- and Post-Tests
What is a Care Conference?
Participation and Involvement in Care Planning
Care Conference Proceedings
Interdisciplinary Team Progress Report
Federal Regulatory Requirement

Section 5: MDS 2.0 Supporting Documentation
Recommendations and Rationale for Use of Forms
RAP Evaluation for Activities of Daily Living, Cognitive Loss/Dementia, Psychosocial Well Being, Mood, and Behavior
Psychotropic Drug RAP Assessment
Analysis, Decision-making, and Consent Regarding Psychoactive Medication
RAP Evaluation for Delirium, Communication, Dental Care, Nutrition, Dehydration/Fluid Maintenance, Tube Feeding and Activities
Physical Restraint Assessment
Urinary Incontinence RAP
RAP Review: Indwelling Catheters
Fall Risk and Skin Assessment and RAP Review
Activity Assessment and RAP Review
Social Service Assessment and RAP Review: Cognition, Mood, Behavior, and Well Being
Social Services Quarterly and Periodic Assessment
Dietary Assessment and RAP Review: Nutrition, Hydration, and Tube Feeding
Dietary Quarterly and Periodic Assessment
Nursing Assessment and History
Psychotropic Drug Side Effect Monitor
Psychoactive Drug Use Progress Note
Side Rail Safety Assessment
Status Evaluation for use of Physical Restraints
Physical Restraint Use Progress Note
Nurse’s Notes: Skin Integrity
Structured Nurse’s Note: Continence Management Programs
Seven-day Core ADL Tracking Tool
Seven-day Mood and Behavior Tracker
ADL Directives
Immediate Needs Care Plan
Core Care Plan
Comprehensive Nurse’s Summary
Interdisciplinary Team Progress Report
Quality Indicator Worksheets for Incontinence, Behavior Symptoms, Pressure Ulcers, Depression, Weight Loss, and ADL Decline

Section 6: Encyclopedia of Care Planning
Steps to Effective Care Planning
Critical Questions for Care Planning, Compliance, and Quality Outcomes
General Care Planning Areas
Federal Certification Requirements and Guidelines for Care Planning
Essential Assessments for On-target Care Plans
Resident Quality Measures/Quality Indicators Worksheet
Suggested Best Practices for MDS 2.0 Supporting Documentation
Evaluating and Acting on Triggered Quality Indicators
Putting the Care Plan Together
Suggested Integrated Care Plan Format: Components of a Usable and Doable Care Plan
ADL Directives
Immediate-needs Care Plan and Problem List
Core Care Plans
Methods for Creating Immediate-need and Care RAP Plans
Sample Free-form Care Plans
Interdisciplinary Team Progress Report
Status of Core Care Plan Goals and Modifications/Additions

Section 7: Structured Care Plans
Abrasion / Bruise
Abuse, Resident to Resident
Abuse, Resident to Staff
Accidents/falls injury, risk for
Adjustment to Facility
ADL decline
Anticoagulant Therapy
Bedfast
Burns
Catheter, Indwelling
Chemotherapy
Coma
Congestive Heart Failure
Constipation / Impaction
Dehydration
Diabetes
Dialysis
Discharge plan
Edema
Elopement Attempts, Poor Decision Maker
Elopement, Decision Making Intact
Falls
Fever with vomiting
Foot lesion with Infection
Foot lesions with dressing
Hemiplegia
Hospice
Hypertension / Hypotension
Internal bleeding
IV Intermittent Pneumonia with Suctioning
IV Therapy, Continuous
Little activity
MRSA / VRE
Multiple Sclerosis
Open Lesions with treatment
Oxygen use
Pain
Pneumonia
Pneumonia, Trach, Suctioning
Pressure ulcers
Psychoactive Medication
Quadriplegia
Radiation
Rashes
Rehab therapy
Respiratory Treatments
Seizure disorder
Septicemia
Skin breakdown, risk for
Skin tear
Suicidal
Surgical wounds with treatment
Trach /Suctioning
Transfusion
Tube Feed 51% or more
Tube feed with Aphasia
Upper respiratory infection
Urinary incontinence
Urinary tract infection
Vent/Trach/Suctioning
Weigh gain, unplanned
Weight loss with Fever
Weight loss, unplanned

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