Care Plan Review

Care Plan Review

• Reviewed facility care plan prepared on 10/10/2023; agreed with current nursing strategies.
• Diagnoses reviewed and updated: T2DM, permanent AF, HTN, bilateral knee OA, and mild vascular dementia.

Past Medical History

• History updated as of 24/10/2023.
• Active: T2DM (12/05/2010), HTN (04/11/2012), permanent AF (18/08/2018), bilateral knee OA (20/02/2019), mild vascular dementia (15/06/2022).
• Inactive: Appendicectomy (14/03/1985), L) Colles' fracture (22/07/2015), herpes zoster (09/11/2020).
• Investigations: HbA1c 7.1 % (15/09/2023), eGFR 58 mL/min/1.73m² (15/09/2023), TTE showing mild LA enlargement and LVEF 55 % (10/03/2023).
• Advance Health Directive: Completed 12/01/2022; Not For CPR or intubation, for ward-based medical management and comfort care only.

Medications

• Current medication list obtained from facility electronic charting system.
• Metformin (Diabex®) 500 mg PO BID, apixaban (Eliquis®) 5 mg PO BID, perindopril (Coversyl®) 5 mg PO daily, paracetamol (Panadol Osteo®) 1,330 mg PO TID, macrogol 3350 (Movicol®) 1 sachet PO daily PRN.
• Checked Primary Medication Chart (PMC); reconciles with GP clinical software with nil discrepancies.

Immunisation

• Influenza (Fluad Quad®) (15/04/2023), Pneumococcal (Prevenar 13®) (10/05/2021), Herpes Zoster (Shingrix® Dose 1) (02/08/2023).

Allergies

• Penicillin (generalised maculopapular rash).

PsychoSocial History and Functional Assessment

• Advance Care Directive is valid, current, and filed in facility records; EPOA is daughter (Sarah Jenkins).
• COVID-19 vaccination up to date (5th dose Pfizer Comirnaty Omicron XBB.1.5 administered 12/09/2023).
• Care provided by RNs, PCAs, facility physiotherapy, and visiting podiatry. Requiring 1x assist with mobility (4WW) and ADLs.
• Routine GP review conducted monthly on-site; PRN reviews as requested by RN.

Significant Events

• Since last review: 1x unwitnessed mechanical fall in room on 02/09/2023 (nil headstrike, nil # on X-ray); physiotherapy mobility review completed; nil hospital admissions; ceased PRN risperidone on 15/08/2023 due to settled BPSD.

Recommendations / Actions

• Continue current falls prevention strategies; ensure sensor mat is active at night and 4WW remains within reach.
• Weigh monthly; notify GP if weight fluctuates by > 2 kg in a month.
• Recent weights: 72.4 kg (01/10/2023), 72.8 kg (01/09/2023), 73.0 kg (01/08/2023).
• Acceptable BP range: SBP 110–150 mmHg, DBP 60–90 mmHg.
• BGL monitoring: Check fasting BGL twice weekly. Notify GP if BGL < 4.0 mmol/L or > 15.0 mmol/L.
• Pain managed with regular paracetamol; monitor via Abbey Pain Scale daily and offer heat packs to knees PRN.
• INR management not applicable (patient on apixaban, monitor renal function 6-monthly).
• Routine dipstick urinalysis not indicated if asymptomatic; send MSU only if acute dysuria, fever, or new-onset delirium.
• Monitor lower limbs weekly for skin integrity and diabetic foot care.
• Nil current psychotropic medications charted; previously ceased risperidone remains unnecessary.
• EPC referrals: Podiatry and Physiotherapy (5 sessions allocated).
• Dr A. Sterling, MBBS, FRACGP
• 24/10/2023
• Filed in GP medical software, uploaded to My Health Record, and copy provided to facility RN.