{"text":"Beluli> \n1 MONITORING OF VITAL SIGNS ~ \nStandard observations (BP, P, T, R, Sa0,) \n- requirement & frequency \nCSM\/Neurovascular observations \nSpecial observations eg. blood glucose, peak \nflow, Neurological obs \nSpecial requirements (0,, chest physio) \nAlM \nTo detect abnormalities and maintain \noptimum function. \nASSESSMENT \/ INTERVENTIONS \n2 IV THERAPY \nPeripheral \/ Central Line - Sites \nUse of Venflon Careplan \nInfusion Chart in use \nNB: 4\u00b0 temp required if patient has an IV \nEarly detection \/ prevention of the probiems \nof IV therapy. \n3 MAINTAINING SAFETY \nLevel of conciousness \nChronic \/ Acute canfusion \nAlcohol withdrawal \nSeizures \n\u2014 Wa'ndering \/ at risk of injury \nTo maintain safety at all times. \n4 MOBILITY \/ MOVING & HANDLING \nAssess DVT risk using'SIGN guidelines \nSpecify limitations\/current ability & aids used \nTraction : \n\" Active\/Passive exercise \nTED Stockings on-admission \n- To prevent \/ reduce the complications of \nreduced mobility. \nTo move the patient safely. \nTo promote independence. \n5 PRESSURE ARE{\\ CARE \nWaterlow score ' \nInterventions \nThe patients skin will remain healthy and \nintact. \n6 PAIN ) \nMonitor effectiveness of analgesia \n- involve patient & medical staff \n- use of Pain Chart \nThe patient will state that he is comfortable. \n7 PERSONAL HYGIENE \nSelf caring or \n= Specify assistance required \nMouth care \nEye care \n\u201cTo mairitain a high standard of personal \nhygiene. \nTo promote independence. \n8 NUTRITIONAL STATUS \nScore: (Use nutrition risk assessment) \nSpecial Dietary requirements \nFasting \/ fluid restrictions \nFluid balance monitoting required \nTo maintain adequate nutritional intake. \nTo promote healing. \n9 URINARY & BOWEL FUNCTION \nIndependent or specify aids used (urinals, \nbedpan etc) \nCatheterised - size \nfree drainage \/ hourly volumes ' \nBowel - Stoma, Aperients \n\u2014 Chart daily \nTo detect any problems with output. \nTo promote independence. \n10 OTHER \ne.g. Wound Care \/ Dressing \nNB: For other wounds, use GRI Tissue Viability Careplan \nThe patient will have clean & dry wounds. \nTo promote Healing. 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