A Guide to Resident Assessment Protocols (RAPs)

and Interdisciplinary Care Plans.

Comprehensive Care Planning for
Long Term Care Facilities:
Plans
By Holly F. Sox, RN, RAC-C
Volume 1
Published by Robin Technologies, Inc.
Creators of Careplans.com
Introduction and Acknowledgements
This book is intended as a starting point for practitioners in the long-term care setting.
The care plans are templates, with space for individualizing based on resident-specific
needs. It is my goal that the care plans and RAP templates will be useful to beginners
and experienced Resident Assessment Coordinators, as well as other interdisciplinary
team members, such as dietitians, social workers and activities professionals.
There are many people and institutions who need to be mentioned and thanked. First, I
want to thank Gary Jorgenson, for giving me the opportunity to work with Robin
Technologies, and to develop this project. It's the greatest job anyone could have.
Thanks to Beth Birch, Dennis Caldwell, Marilynn Comar, Keith Paul, Tom Porter, Cheryl
Terry and Mel Stepp, for providing leadership and serving as examples to me in
administration. Thank you to AANAC for providing a foundation of knowledge and
training, and a network for NACs across the country, to share our knowledge and
support for each other. Thank you to the members of CMDG, the Case Mix Discussion
Group for stimulating my interest and desire for more knowledge.
My biggest thanks go to my family. To my mom and dad, thanks for paving the way into
this profession of nursing, and for being such wonderful examples of the kind of nurse
that I always want to be. And, to Mike, Cody and Mikey, thank you for letting me sit at
my
computer till late at night, writing one more care plan.
About the Author
Holly Sox graduated Magna cum laude with a B.S. in Nursing
from the University of South Carolina in 1988. After graduating,
she has worked as an MDS Coordinator, Clinical Nurse, Special
Procedures Nurse, Office Nurse, as well as a Staff Nurse. In
2003, she was awarded NAC of the Year by the American
Association of Nurse Assessment Coordinators (AANAC).
Currently, Holly serves as the Resident Assessment Director at
J F Hawkins Nursing Home in Newberry, South Carolina and as
Clinical Editor for Careplans.com.
Holly Sox, RN, RAC-C
TABLE OF CONTENTS
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Introduction to the RAPs
RAP Templates
1. Activities

2. ADL/Functional Rehabilitation Potential with ADL Supplement

3. Behavioral Symptom
4. Cognitive Loss
5. Communication
6. Dehydration
7. Delirium
8. Dental Care
9. Falls
10. Feeding Tubes
11. Mood State
12. Nutritional Status
13. (Optional) Pain
14. Physical Restraints
15. Pressure Ulcers
16. Psychosocial Well-Being
17. Psychotropic Drug Use
18. Urinary Incontinence/Indwelling Catheters
19. Visual Function
20. Sample Completed RAP
Introduction to Care Planning
RAP Care Plan Templates
1. Activities- Dependent on Staff for Activities
2. Activities- Little or No Activity Involvement
3. ADL- Self-Care Deficit
4. ADL- Limited Mobility
5. Behavior Problem
6. Behavior Problem- Refusing Feeding
7. Behavior Problem- Wandering
8. Cognitive Loss
9. Communication- Impaired Expressive or Receptive Communication
10. Communication- Aphasia
11. Dehydration/Fluid Balance- Potential or Actual Dehydration
12. Dehydration/Fluid Balance- Fluid Overload
13. Delirium or Acute Confusional Episode
14. Dental Care
15. Falls
16. Feeding Tubes
17. Mood Problem
18. Mood State- Depression
19. Nutrition- Potential or Actual Nutritional Problem
20. Nutrition- Obesity
21. Pain
22. Physical Restraints
23. Pressure Ulcer- Potential or Actual
24. Psychosocial Well-Being- Potential for Adjustment Reaction
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25. Psychosocial Well-Being Problem

26. Psychotropic Drug Use

27. Urinary Incontinence
28. Indwelling Catheter
29. Vision Problem
Care Plans for Disorders of the Cardiovascular System
1. Potential for Altered Cardiac Output
2. Angina
3. Congestive Heart Failure
4. Coronary Artery Disease
5. Deep Vein Thrombosis
6. Dysrhythmia
7. Hypertension
8. Hypotension
9. Pacemaker
10. Peripheral Vascular Disease
11. Ineffective Tissue Perfusion
Care Plans for Disorders of the Endocrine System
1. Diabetes Mellitus
2. Diabetic Ketoacidosis (DKA)
3. HHNK (Hyperglycemic Hyperosmolar Non Ketotic Syndrome)
4. Hyperparathyroidism
5. Hyperthyroidism
6. Hypothyroidism
Care Plans for Disorders of the Gastrointestinal System
1. Colostomy
2. Constipation
3. Diarrhea
4. Diverticulosis
5. Gastroesophageal Reflux Disease (GERD)
6. GI Bleeding
7. Hemorrhoid
8. Hepatitis
Care Plans for Disorders of the Genitourinary System
1. Benign Prostate Hypertrophy
2. Chronic Renal Failure
3. Urinary Retention
4. Urinary Tract Infection
Care Plans for Disorders of the Integumentary System/Connective Tissue
1. Eczema
2. Foot Problems
3. Lupus
4. Psoriasis
5. Scabies
6. Scleroderma
7. Surgical Wound
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Care Plans for Disorders of the Musculoskeletal System
1. Amputation
2. Arthritis (DJD/Osteoarthritis/Gout/Rheumatoid)
3. Fracture
4. Hip Fracture
5. Osteoarthritis
6. Osteoporosis
Care Plans for Disorders of the Neurological System

1. Cerebrovascular Accident
2. Huntingtons Disease
3. Multiple Sclerosis
4. Parkinsons Disease
5. Seizure Disorder
Care Plans for Disorders of the Respiratory System
1. Chronic Obstructive Pulmonary Disease/Asthma
2. Ineffective Airway Clearance
3. Tracheostomy
4. Tuberculosis
Care Plans for Disorders of the Sensory Organs
1. Eye discomfort
2. Hearing Loss
Care Plans for Hematologic/Oncologic Disorders
1. Anemia
2. Cancer
3. Thrombocytopenia
Care Plans for Medication or Treatment Effects
1. Anticoagulant
2. Chemotherapy
3. Dialysis
4. Intravenous Therapy
5. Radiation
Care Plans for Psychosocial Issues
1. Death and Dying Issues
2. Potential Abuse
3. Sexual Dysfunction
4. Short-Term Stay
Care Plans for Safety and Security Issues
1. Potential for Elopement
2. Smoking
PLAN OF CARE
Problem(s) Goal(s) Approach(es) Dept Review
2004 careplans.com Robin Technologies Inc. 670 Lakeview Plaza Blvd., Suite J.
Worthington OH 43085 614-888.3001 www.robintek.com
Resident Name ID# Room # Physician
Behavior problem: wandering
related to
* Alzheimers disease
* Other dementia
* CVA
* Delirium
* New environment
* New routine
* Mood problem
* Relationship problem

Will wander safely within

environment aeb no falls,
elopement events, injury
through review date.
OR
Will have more purposeful
behavior with wandering
less than
Daily/weekly/monthly by
review date.
Monitor behavior and
attempt to determine
pattern, frequency, intensity.
Review for recent changes
such as bed move, room
change, medication
changes, change in
cognitive function, new staff
members, change in
treatment program, loss of
family member.
Attempt to determine cause
of wandering and relieve, if
possible. (ie, boredom,
looking for someone or
something)
Anticipate and meet needs.
Respond promptly to all
requests for assistance.
Keep familiar routines intact
if possible.
Maintain familiar items in
environment, with well-lit
room.
Praise any purposeful
movements, non-wandering
behavior.
Walk with resident daily or
more frequently, with
purpose.
Provide a program of
activities to minimize
potential for wandering while
meeting need for
social/cognitive stimulation.
Mark room door with name

or familiar photo, to aid in

remembering room location.
Use security alarm bracelet
or other sensor system as
needed to reduce risk of
elopement from facility.
Ensure that hallways are
free from spills, clutter and
other hazards.
N
N
N
ALL
ALL
ALL
ALL
N,SW,ACT
ACT
ACT
N
HSK
SAMPLE