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3sHealth, NISS Copyright. Not to be reproduced in any manner. 1 of 12 SRCP-011.2 Dec 2016
Individual Care Plan: Stroke Rehabilitation Admitting diagnosis
Ischemic_________________ Hemorrhagic____________________
Confirmed diagnosis
Other Medical Conditions Age
Surgery/Confinement (type, date) Allergies: (describe reaction(s))
Drug:
Food:
Latex:
Environment:
See Facility-specific Allergy/Intolerance record (if applicable)
Family physician: Attending physician:
ORDERED
DATE TESTS/X-RAYS COMPLETED
DATE ID
RESULTS
RETURNED
DATE INTERVENTIONS
ORDERED
DATE CONSULTS INITIATED
DATE
Occupational Therapist
Physical Therapist
Speech Language Path.
Social Worker
Metabolic & diabetic education centre (MEDEC)
Ordered
Date DISCHARGE PLANNING
Initiated Date
Tentative Discharge Date
MISCELLANEOUS INFORMATION
Key Contact: Relationship: Health Directives: Yes No On file Location:
Phone: (H): (W) (C)
Other: Immunizations (date)
Influenza:
Pneumovax:
Legal Medical Substitute Decision Maker: Treated for AROs (date)
Proxy Personal Guardian Nearest relative VRE:
Phone: (H) (W) (C) MRSA:
Financial Power of Attorney: (include ph#) Other:
Rew
rit
ten
da
te:
3sHealth, NISS Copyright. Not to be reproduced in any manner. 2 of 12 SRCP-011.2 Dec 2016
DIAGNOSTIC PROCEDURE PROFILE
ORDERED
DATE TESTS/X-RAYS COMPLETE
D DATE
ID
RESULTS
RETURNED
DATE INTERVENTIONS
ORDERED
DATE CONSULTS
INITIATED
DATE
EXTERNAL APPOINTMENTS AND LOCATION DATE TIME METHOD OF TRAVEL ACCOMPANIED
BY:
DATE AND TIME
OF RETURN
3sHealth, NISS Copyright. Not to be reproduced in any manner. 3 of 12 SRCP-011.2 Dec 2016
INDIVIDUAL CARE PLAN STROKE REHABILITATION
INITIATOR DESIRED OUTCOME REVIEW
DATE ID
INITIATED
DATE ID
INTERVENTIONS
DISC DATE
ID
PE
RS
ON
AL
HY
GIE
NE
Bathing and dressing self-care deficit related
to neuromuscular impairment.
Increase the client’s ability to self perform
ADLs.
Upper ADL’s AM and PM
Bathing (neck down to waist excluding back)
Wash, rinse, dry
Total
Maximum
Moderate
Minimal
Supervised
Independent
Dressing- Upper Body
Total
Maximum
Moderate
Minimal
Supervised
Independent
Lower ADL’s AM and PM
Bathing from the waist down: wash, rinse, dry
Total
Maximum
Moderate
Minimal
Supervised
Independent
Dressing- Lower Body
Total
Maximum
Moderate
Minimal
Supervised
Independent
3sHealth, NISS Copyright. Not to be reproduced in any manner. 4 of 12 SRCP-011.2 Dec 2016
INITIATOR DESIRED OUTCOME REVIEW
DATE ID
INITIATED
DATE ID
INTERVENTIONS DISC
DATE ID
PE
RS
ON
AL
HY
GIE
NE
(C
ON
TIN
UE
D)
Risk of self-care deficit and altered oral
mucosa related to neuromuscular impairment and
fatigue.
Intact oral mucosa. Oral care minimum twice a day (bid).
Oral Care: Brushing teeth AM and PM
Total
Maximum
Moderate
Minimal
Supervised
Independent
Dentures Upper Lower
Grooming self-care deficit related to neuromuscular
impairment.
Increase the client’s ability to self perform
daily grooming.
Comb/ Brush hair AM
Total
Maximum
Moderate
Minimal
Supervised
Independent
Wash Hands before meals
Total
Maximum
Moderate
Minimal
Supervised
Independent
Shaving/ Apply Make up in AM
S
Total
Maximum
Moderate
Minimal
Supervised
Independent
3sHealth, NISS Copyright. Not to be reproduced in any manner. 5 of 12 SRCP-011.2 Dec 2016
INDIVIDUAL CARE PLAN STROKE REHABILITATION
INITIATOR DESIRED OUTCOME REVIEW
DATE ID
INITIATED
DATE ID
INTERVENTIONS DISC DATE
ID
EL
IMIN
AT
ION
Risk of altered pattern of urinary elimination
related to neurosensory deficits.
Manages urinary elimination.
Instruct client to void at regular intervals
Scheduled voids:
Q____________hours on days
Q____________hours on nights
Incontinent: Day Night
Incontinent briefs worn Day Night
Size Small Medium Large
Uses urinal / Uses bedpan
Uses commode: Day Night
Bathroom: Day Night
Continent: Day Night
Risk of infection related to indwelling
catheter.
No evidence of Urinary Tract
Infection.
Indwelling catheter
#_________ with _________mls of NS
Change due: _____________
_____________
Initiate bladder retraining program
Risk of constipation related to decreased mobility, decreased
fluid intake, decreased fiber and
neurosensory deficits.
Maintains regular bowel evacuation.
Encourage fluid and fiber intake
Offer fluids q ____________hrs during day
Monitor daily bowel movement
If there is no bowel movement , implement
physician ordered bowel care
Incontinent of bowel
Briefs worn: Small Medium Large
Uses bedpan
Uses commode
Uses Bathroom
Continent of bowel
3sHealth, NISS Copyright. Not to be reproduced in any manner. 6 of 12 SRCP-011.2 Dec 2016
INITIATOR DESIRED OUTCOME REVIEW
DATE ID
INITIATED
DATE ID
INTERVENTIONS
DISC DATE
ID E
LIM
INA
TIO
N (
CO
NT
INU
ED
)
NU
TR
ITIO
N
Risk of inadequate nutrition related to
neurosensory deficits.
Maintain adequate nutrition and
hydration.
Diet:
Enteral feeds:
NPO
Ensure dentures are in place (if applicable)
Feed: Total
Maximum
Moderate
Minimal
Supervised
Independent
Risk of choking / aspiration related to
dysphasia.
Avoid aspiration.
Swallowing assessment
Reinforce SLP recommendations:
Ensure client is in an appropriate position:
_______ Upright at 90 degrees for all meals
________Upright for 30 minutes after meals
Observe for coughing / choking during oral
intake
Ensure mouth care after meals and check for
pocketing
3sHealth, NISS Copyright. Not to be reproduced in any manner. 7 of 12 SRCP-011.2 Dec 2016
INDIVIDUAL CARE PLAN STROKE REHABILITATION
INITIATOR DESIRED OUTCOME REVIEW
DATE ID
INITIATED
DATE ID
INTERVENTIONS
DISC DATE
ID
MO
BIL
ITY
Risk of altered mobility related to
neuromuscular impairment/ dysfunction.
Client provided with task orientation training which is
progressively adapted and directed at
enhancing motor control, sensory and functional ability with
increasing client independence.
TLR Mobility record
Transfer to right left side
Range of motion on unit twice daily
Sit/ stand exercises daily on unit (11-13 reps)
Walk with person assist ________ X daily
Provide minimum 1 hour daily 6 days a week of
task orientated training on the unit outside of
direct therapy time
Risk of shoulder subluxation related to
poor glenohumeral joint alignment,
decreased passive ROM and decreased
muscular, ligamentous and tendinous function
around shoulder.
Client is able to verbalize/ report pain
sensation. Pain is reduced or eliminated.
Provide analgesia PRN
Encourage client to handle affected limb
Support limb and hand
Position affected limb in bed: elbow straight,
hand open position, elevate on pillow to
decrease edema
Support shoulder / arm on a firm surface
when sitting
Hemitray
Arm trough
Elbow / wrist splint
Other:
Risk of activity intolerance related to
fatigue and pain.
Will increase tolerance for activity.
Activity as tolerated
Up to chair X ________hours
Risk of Unilateral neglect related to
neuro deficits.
Recognize/ acknowledge affected
limb
Reinforce and teach how to care for affected
limb
3sHealth, NISS Copyright. Not to be reproduced in any manner. 8 of 12 SRCP-011.2 Dec 2016
INITIATOR DESIRED OUTCOME REVIEW
DATE ID
INITIATED
DATE ID
INTERVENTIONS
DISC DATE
ID M
OB
ILIT
Y (
CO
NT
INU
ED
)
Risk of deep vein thrombosis (DVT)
related to decreased mobility.
Prevention or early detection of DVT.
Bilateral below the knee AES/ TED stockings
Assess for DVT q shift
Observe and document extremity edema BID
OB
SE
RV
AT
ION
S A
ND
ME
AS
UR
EM
EN
TS
Risk of altered Vital Signs and/or
neurological condition related to acute stroke and other medical co-
morbidities.
Detect alterations in Vital Signs and Blood Pressure. Maintain a Blood Pressure less
than or equal to 140/90 or for diabetic 130/90.
Monitor vital signs
Blood glucose monitoring (if applicable)
Height and weight on admission
Weight q weekly on ___________________
Risk of pain related to neuro changes and
immobility.
Maintain optimum comfort.
Assess and document pain (PQRST)
Offer analgesia PRN, document effectiveness
Refer to mobility record for positioning
Risk of skin breakdown related to
deficits in mobility and sensation.
Maintain skin integrity.
Braden Scale score
Observe skin integrity BID
Turn and position q ___________hours
Turn and position self
Ensure positioning with pressure relief in
wheelchair
3sHealth, NISS Copyright. Not to be reproduced in any manner. 9 of 12 SRCP-011.2 Dec 2016
INDIVIDUAL CARE PLAN STROKE REHABILITATION
INITIATOR DESIRED OUTCOME REVIEW
DATE ID
INITIATED
DATE ID
INTERVENTIONS
DISC DATE
ID
OB
SE
RV
AT
ION
S A
ND
ME
AS
UR
EM
EN
TS
(C
ON
TIN
UE
D)
ME
DIC
AT
ION
S
Risk of alteration in body requirements and
comfort related to acute stroke and/ or other co-mobidities.
Maintain optimal body requirements and
comforts.
Administer medications as ordered by the
physician – see MAR
Administer appropriate analgesia as required
to ensure patient comfort
3sHealth, NISS Copyright. Not to be reproduced in any manner. 10 of 12 SRCP-011.2 Dec 2016
INITIATOR DESIRED OUTCOME REVIEW
DATE ID
INITIATED
DATE ID
INTERVENTIONS
DISC DATE
ID T
RE
AT
ME
NT
S A
ND
PR
OC
ED
UR
ES
Risk of infection related to physical
environment and skin integrity.
Prevent infection and transfer of micro
organism.
Use proper hand washing technique and
teach to client
Adhere to routine practice procedures
Risk of respiratory complications related to decreased mobility.
No evidence of respiratory
complications.
DB & C exercises q ____________
Risk of infection related to ARO
Prevent infection and transmission of micro-
organisms
Isolation precautions
Type:
TE
AC
HIN
G
Risk of knowledge deficit related to disease process,
diagnostic procedures, 2o to cerebral injury.
Client, families and caregivers will have
appropriate and realistic expectations about role changes,
availability of services and resources in
changing care environment.
Assess client and family knowledge and
determine needs and readiness for education
and training
Correct misinformation
Include in the teaching: what is a stroke, risk
factors and risk management of a stroke and
information on medications and actions
3sHealth, NISS Copyright. Not to be reproduced in any manner. 11 of 12 SRCP-011.2 Dec 2016
INDIVIDUAL CARE PLAN STROKE REHABILITATION
INITIATOR DESIRED OUTCOME REVIEW
DATE ID
INITIATED
DATE ID
INTERVENTIONS
DISC DATE
ID
SA
FE
TY
Risk of injury related to sensory- altered
mobility and or visual, special deficits.
Maintain safety and prevent physical
injury.
Complete TLR mobility record- ensure
correct TLR logos are above client’s bed &
on wheelchair
Observe for impulsivity and impaired
judgment
Use repetition and step commands for
transfer
Ensure and enforce use of wheelchair
brakes, seat belts and proper footwear
Call bell within reach
Side rails up X___________
Ensure environment is organized and free of
hazards
Facility-specific fall risk assessment
Risk of wandering related to altered thought process.
Will remain safe on premise.
Watch for S&S of agitation/restlessness
Re-orientate PRN
PS
YC
HO
SO
CIA
L
Risk of client’s health care preferences may have changed related
to recent health issues and not documented.
Client will be approached by health
care team to participate in advance
care plan.
Provide avenue for timely, sensitive,
communication between client, family, and
health care providers to develop or review
advance care plans
Risk of anxiety, loneliness,
dependency and lack of confidence related
to recent health issues.
Client is actively participating in
rehabilitation activities and expresses
emotions related to health issue.
Give clear information regarding care plan
Establish Yes / No reliability
Give opportunity for the client to express
feelings
Encourage family involvement
Assess for and discuss stages of grieving
of loss of function
Risk of ineffective coping and
psychosocial needs related to anticipated
grief.
Appropriate coping skills are encouraged.
Observe for S&S of depression
Leave of absence as ordered______________
3sHealth, NISS Copyright. Not to be reproduced in any manner. 12 of 12 SRCP-011.2 Dec 2016
INITIATOR DESIRED OUTCOME REVIEW
DATE ID
INITIATED
DATE ID
INTERVENTIONS
DISC DATE
ID
