Situation Monitoring: Exercise Sheet (Mrs. Valdez)

TeamSTEPPS Long-Term Care Version: Module 4

The Long-Term Care version of TeamSTEPPS adapts the core concepts of the TeamSTEPPS program to reflect the environment of nursing homes and other other long-term care settings such as assisted living and continuing care retirement communities. The examples, discussions, and exercises below are tailored to the long-term care environment.



Read the following at the start of the Mrs. Gloria Valdez optional exercise.


An initial care plan meeting is scheduled for Mrs. Gloria Valdez, a woman who has recently come to live here at [NURSING HOME NAME]. Although the whole care team is invited, it is a busy day.

Staff in attendance are the nurse, social worker, activity assistant, and occupational therapist. Those not in attendance are Mrs. Valdez, her daughter Rose, the nursing assistant, and the housekeeper.

Mrs. Valdez does not attend, because she is very confused and anxious today and the nurse has decided that her attendance would not be useful to the process. Rose, her daughter, works days and cannot make the meeting. She will try to take time off to attend future meetings. The nursing assistant is very busy and does not come; two staff have called in sick. The housekeeper is not a member of the interdisciplinary care team and never attends.

Care Plan Questions to Consider


Provide the following questions to the care planning team (and the audience) for consideration when creating Mrs. Valdez's initial plan of care.


  • From what we know, what are Mrs. Valdez's needs and preferences that may be critical for maintaining or enhancing her personhood?
  • What might support Mrs. Valdez's well-being?
  • What are things about Mrs. Valdez every staff person should know?
  • What are some care approaches and activities that should be avoided?
  • What are some of her needs that should be included in her care plan?

Role Information


Use the following information to prepare envelopes for each designated role on the care plan team. Place the information for each role (e.g., Mrs. Valdez) inside the designated envelope.

Mrs. Valdez

  • I have always prided myself on my appearance.
  • Strongly spiritual and religious, I have practiced in a Roman Catholic tradition. I attended Mass several days a week.
  • I am very private and modest.
  • I have always gone to bed late at night. I like to listen to the radio in bed.
  • I am fiercely independent.


  • Mrs. Valdez has had much trouble finding her room and becomes overwhelmed and anxious.
  • She often states, "I need to go home and feed my children."
  • She often states, "Where is Carlos? I need to find Carlos!"
  • Mrs. Valdez collects food from meals and stores it in her bedroom drawer.
  • She enjoys talking to me as I clean her room.

Activity Assistant

  • Mrs. Valdez is very social and enjoys being with people.
  • She responds with affection and joy to children.
  • Has a strong need to take care of others and is sensitive to the needs of others.
  • Loves gardening and flowers.
  • Enjoys singing and spontaneously breaks into song when music is being played.


  • Mrs. Valdez has lost much of her verbal ability to put her thoughts into clear, complete messages.
  • She has dementia of the Alzheimer's type and was diagnosed 7 years ago.
  • She is prescribed an antidepressant medication.
  • She has an appetite for snacks throughout the day.
  • Rose, her daughter, has been coming twice a day since Mrs. Valdez's admission 2 weeks ago.


  • Mrs. Valdez is uncomfortable with male caregivers.
  • She has urinary incontinence that she tries to manage with napkins and paper products.
  • She eats breakfast well but eats poorly at other meals.
  • She becomes overwhelmed by loud noise and confusion around her.
  • She is anxious during bathing and prefers to remain covered.

Social Worker

  • Mrs. Valdez was a school teacher for 30 years, mostly first and second grades.
  • She had lived with her daughter Rose and her family for the past 3 years.
  • Rose is very involved in her life and is concerned about her care.
  • Her husband died 12 years ago; his name was Antonio.
  • She had a son, Carlos, who died when he was age 8; this has been a powerful sorrow throughout her life.

Rose, Mrs. Valdez's Daughter

  • My mother suffered spousal abuse.
  • My mother has not taken off her clothes for bathing recently and became physically defensive if undressed.
  • I am very concerned that she will not have meaningful things to do here.
  • My mother's Argentinean heritage is very important to her. I am concerned that it will not be understood and respected.

Occupational Therapist

  • Mrs. Valdez needs activities of daily living broken into simple steps with verbal cueing for success and participation in care.
  • She does well when she can walk outside. This supports her mobility and helps her to channel her energy into positive activity. It also supports her love of flowers and nature.
Page last reviewed November 2012
Page originally created November 2012
Internet Citation: Situation Monitoring: Exercise Sheet (Mrs. Valdez). Content last reviewed November 2012. Agency for Healthcare Research and Quality, Rockville, MD.