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Designed for the Unique Needs
of Homecare Providers
This site provides homecare clinicians with access to chronic care management models, best practices and downloadable resources for homecare patients.
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"The body of knowledge that serves as the rationale for nursing practice determines the areas of specialty to develop as well as the manner in which that knowledge is organized, tested and applied." -Carper, 1978
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Diabetes
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Problem Solving
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Plan
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| A self-care action plan should include the appropriate patient response to scenarios common in patients with heart failure. This includes the response to fluid overload or dehydration as well as to chest pain.
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It is important to work in tandem with the provider in order to make appropriate referrals. A list of community and national resources can be made available to the patient and/or the caregivers in order to assist them in initiating these relationships.
Include specific measurable patient goals in the plan of care. Use "Plan Characteristics” below as tools to build a nursing plan and find resources to set and to reach goals.
Plan characteristics should include:
- Includes a defined time frame.
- Developed with the patient and reflects what the patient wants to achieve.
- Considers patient’s readiness to change.
- Outlines the support they need to make changes.
- Includes individualized interventions to meet patient’s goals*.
*Under implement category you will find tools to help you carry out patient goals.
Important to consider when doing your plan of care:
- Target goals for A1c (including preprandial and postprandial target goals)
- Target goals for blood pressure
- Target goals for cholesterol (LDL, HDL, Triglycerides).
- Current recommended standards of clinical care
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Four Steps to Control Your Diabetes for Life
(pdf)
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Feb 3rd, 2011
A 30-page booklet from NDEP, updated in 2006, that explains basic diabetes care and control and includes pages to keep a record of care received and progress toward goals for blood glucose, cholesterol and blood pressure.
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Action Plan for Diabetes
(Web Page)
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Feb 3rd, 2011
A proven system with all the essential information you need to safely and effectively manage type 1 and type 2 diabetes and prediabetes for long term. Action Plan for Diabetes will help you do more than survive; you will thrive and feel better than you ever thought possible.
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Diabetes Self Management Behavior Goals
(pdf)
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Feb 2nd, 2011
Chart for Patient to Write in Behavior Goals to Better Manage Diabetes
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