Resident Name: [Client's Name]
Date of Birth: [DOB]
Age: 34 years old
Date of Plan Initiation: [Date]
Facility: [Adult Family Home Name]
Primary Diagnosis: Mental health disorder, agitation, anxiety, hypertension, insomnia, mood swings
Level of Care: 24-hour supervision and support
Care Goals
Ensure physical and mental well-being by managing symptoms and promoting stability.
Promote emotional and psychological stability by reducing anxiety, agitation, and mood swings.
Encourage quality sleep through non-pharmacological and medical interventions.
Manage hypertension through medication adherence, dietary control, and lifestyle modifications.
Enhance daily functioning and independence while ensuring safety.
Provide a structured and therapeutic environment to reduce triggers for agitation and anxiety.
Assessment of Needs and Support Plan
1. Mental Health and Emotional Support
Encourage daily structured routines to provide predictability and reduce stress.
Provide therapeutic activities (e.g., music therapy, mindfulness, journaling).
Ensure regular mental health check-ins with the care team and/or assigned therapist.
Implement de-escalation techniques during periods of agitation or anxiety.
Offer one-on-one counseling support as needed.
2. Agitation and Mood Swings Management
Identify triggers and work on minimizing them (e.g., loud noises, crowded spaces).
Utilize calming techniques such as breathing exercises, sensory items, or a quiet space.
Administer prescribed psychiatric medications as ordered and monitor for side effects.
Maintain consistent staff interactions to build trust and comfort.
3. Anxiety Reduction
Offer guided relaxation sessions (e.g., meditation, light yoga).
Encourage journaling or verbal expression of emotions.
Provide reassurance and redirection when displaying anxious behaviors.
4. Hypertension Management
Administer antihypertensive medications as prescribed and monitor for compliance.
Check blood pressure daily and report significant changes.
Maintain low-sodium diet with balanced nutrition.
Encourage mild to moderate physical activities (e.g., walking, stretching).
5. Insomnia Management
Implement consistent bedtime routine (e.g., no screen time, relaxation techniques).
Offer sleep-friendly environment (dim lighting, quiet setting).
Administer sleep aids only if prescribed and monitor response.
Encourage daytime activities to reduce excessive napping.
6. Activities of Daily Living (ADLs) and Socialization
Assist with personal hygiene, grooming, and dressing as needed.
Support engagement in group activities to promote social interaction.
Provide opportunities for light household tasks to encourage independence.
Safety and Crisis Management
24-hour supervision to ensure safety and prevent self-harm or harm to others.
Emergency protocol in place in case of medical or mental health crisis.
Staff trained in crisis intervention and de-escalation techniques.
Regular staff meetings to assess the effectiveness of the care plan.
Review and Updates
Care plan will be reviewed every 3 months or as needed based on changes in condition.
Family and healthcare providers will be involved in updates.
Adjustments will be made as necessary to ensure the best possible care outcomes.
Care Team Signatures
Resident: ________________________
Family/Guardian: ________________________
Primary Caregiver: ________________________
Facility Manager: ________________________
Date: ________________________
Date of Birth: [DOB]
Age: 34 years old
Date of Plan Initiation: [Date]
Facility: [Adult Family Home Name]
Primary Diagnosis: Mental health disorder, agitation, anxiety, hypertension, insomnia, mood swings
Level of Care: 24-hour supervision and support
Care Goals
Ensure physical and mental well-being by managing symptoms and promoting stability.
Promote emotional and psychological stability by reducing anxiety, agitation, and mood swings.
Encourage quality sleep through non-pharmacological and medical interventions.
Manage hypertension through medication adherence, dietary control, and lifestyle modifications.
Enhance daily functioning and independence while ensuring safety.
Provide a structured and therapeutic environment to reduce triggers for agitation and anxiety.
Assessment of Needs and Support Plan
1. Mental Health and Emotional Support
Encourage daily structured routines to provide predictability and reduce stress.
Provide therapeutic activities (e.g., music therapy, mindfulness, journaling).
Ensure regular mental health check-ins with the care team and/or assigned therapist.
Implement de-escalation techniques during periods of agitation or anxiety.
Offer one-on-one counseling support as needed.
2. Agitation and Mood Swings Management
Identify triggers and work on minimizing them (e.g., loud noises, crowded spaces).
Utilize calming techniques such as breathing exercises, sensory items, or a quiet space.
Administer prescribed psychiatric medications as ordered and monitor for side effects.
Maintain consistent staff interactions to build trust and comfort.
3. Anxiety Reduction
Offer guided relaxation sessions (e.g., meditation, light yoga).
Encourage journaling or verbal expression of emotions.
Provide reassurance and redirection when displaying anxious behaviors.
4. Hypertension Management
Administer antihypertensive medications as prescribed and monitor for compliance.
Check blood pressure daily and report significant changes.
Maintain low-sodium diet with balanced nutrition.
Encourage mild to moderate physical activities (e.g., walking, stretching).
5. Insomnia Management
Implement consistent bedtime routine (e.g., no screen time, relaxation techniques).
Offer sleep-friendly environment (dim lighting, quiet setting).
Administer sleep aids only if prescribed and monitor response.
Encourage daytime activities to reduce excessive napping.
6. Activities of Daily Living (ADLs) and Socialization
Assist with personal hygiene, grooming, and dressing as needed.
Support engagement in group activities to promote social interaction.
Provide opportunities for light household tasks to encourage independence.
Safety and Crisis Management
24-hour supervision to ensure safety and prevent self-harm or harm to others.
Emergency protocol in place in case of medical or mental health crisis.
Staff trained in crisis intervention and de-escalation techniques.
Regular staff meetings to assess the effectiveness of the care plan.
Review and Updates
Care plan will be reviewed every 3 months or as needed based on changes in condition.
Family and healthcare providers will be involved in updates.
Adjustments will be made as necessary to ensure the best possible care outcomes.
Care Team Signatures
Resident: ________________________
Family/Guardian: ________________________
Primary Caregiver: ________________________
Facility Manager: ________________________
Date: ________________________
