Writing Your Care Plan.
A statement of something of concern to the resident or the nursing staff or both.
An actual or possible difficulty/limitation/risk resulting from the resident’s illness or condition, which can be helped, resolved or prevented by nursing intervention.
Medical diagnoses refers to illness, nursing problems focus on the resident’s response to the illness/condition.
Problems arise from diseases/illnesses / conditions that the resident has and how these affect the resident for this domain.
If the resident has no actual or potential problems in this domain, record this under the problem heading.
Goals are statements of what the resident and / or nursing want to achieve.
Goals should be SMART – specific, measurable, achievable, realistic and have a time frame where appropriate.
Goals often fall into one of the following categories:
Maintenance: To maintain the resident at their current level of ability/functioning.
Prevention: To prevent / reduce the likelihood of something happening eg a risk / deterioration in condition/ability etc.
Palliative: To provide / maintain comfort.
Restorative: To restore /improve ability/condition etc.
If the resident has no actual or potential problems in a particular domain, the goal might be to maintain their ability /independence in that domain.
The care plan provides information / instructions on how the resident is cared for on a day-to-day basis and should include:
Remember, even, if the resident has no actual or potential problems in a particular domain, there may be information that staff need to know about any preferences, abilities etc. as and if relevant to the domain.
If the information is already recorded in another domain, there is no need to duplicate, just refer the reader to the other domain(s).
Example of Problem/Need: Mary is unable to make everyday decisions for him/herself because of her cognitive impairment related to dementia.
Goals: Mary will be able to make everyday decisions with assistance.
Care Plan Prompts.