ADLs: Plan of Care Key Steps Diagnosis and functional ability identification Develop plan of care
Implement selected interventions
Key Elements Identify clinical conditions impacting ADL decline Develop Plan of Care • Match interventions with specific conditions • Coordinate plan and care with health care team, resident, family, caregivers Implement Selected Interventions • Functional training in self-care ADLs • Functional training in simulated environments • Exercise • Device and equipment use and training • Task adaptation • Barrier accommodation or modification • Safety awareness training • Injury prevention or reduction education • Restorative nursing program • Family, caregiver education, training • Referrals to other health professionals as appropriate
[Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9-744]
Manage general health throughout all stages of treatment
Continue to monitor: • Comorbid conditions • Acute illness • Nutrition, hydration • Bowel, bladder function Prevent complications from developing: • Deep vein thrombosis • Dysphagia, aspiration • Skin breakdown • UTI • Falls • Loss of ROM • Immobility • Edema • Adverse drug reaction • Depression From Clinical Practice Guideline, Post-Stroke Rehabilitation, Quick Reference Guide 16, AHCPR
Measure, monitor, and document outcomes
Record clinical condition, expected outcomes, frequency, duration of interventions, resp to treatment, education, progress toward goals
Review and revise plan of care
Review, revise plan of care Based on resident’s response, team feedback
MO-03-09-NHAD April 2003 This material was prepared by Primaris under contract with the Centers for Medicare & Medicaid Services (CMS). The contents presented do not necessarily reflect CMS policy. Version 03/11/2003
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