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. For example: Mary has no problems with breathing.
Goals are statements of what the resident and / or nursing want to achieve.
Goals should be SMART – specific, measurable, achievable, realistic and have a timeframe 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 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:
What the resident can do.
What assistance, if any the resident needs in this domain.
Likes / dislikes/ preferences relevant to this domain.
Aids / equipment used and how specific to this domain.
Involvement of other healthcare professionals and implications for care.
Specific interventions to be carried out to address problems / risks related to this domain.
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).
Breathing Care Map
Problems/Needs:
Describe the problem/need in the residents words if possible, if not, describe in your own words
Identify any related factors.
Identify care to address the problem/need.
Risks: Are there any risks to the resident or others because of their breathing difficulties?
Describe the risk.
State who could be harmed and how.
Identify care to address the risk.
Use the generic risk assessment if required.
Likes/ Dislikes:
What are the resident’s preferences?
For example:
Prefers a particular position to ease breathing difficulties.
Prefers to receive nebulisers at particular times of the day.
Prefers either a face mask or nasal cannula.
Goals:
What do we / the resident want to achieve?
SMART Goals.
Allied Healthcare Professionals
Involved e.g., General Practitioner, Consultant.
Describe their input and how this can be applied to the residents every day care.
Abilities:
What can the resident do?
For example:
Able to breathe with no difficulty.
Able to alert staff if experiencing any difficulties with breathing.
Able to be involved in the management of oxygen therapy or nebulisers.
Aids/Equipment:
Identify any aids or equipment that is used to help with the resident’s breathing e.g. oxygen, nebulisers, inhalers, etc.
Identify how they will be used.
Example.
Goals:
To reduce episodes of breathlessness.
Care Plan.
Describe how the problem affects the resident on a daily basis.
Document any methods required to provide reassurance to relieve any anxiety the resident may experience that is associated with dyspnoea e.g. fear of dying or fear of suffocation.
Document the need to eliminate any non-essential activities for the resident, if breathless on activity.
Document any interventions that may be used to maintain the resident’s mobility and independence as far as possible.
Document the need for small frequent meals and drinks if the resident is experiencing shortness of breath whilst eating and drinking.
Document any oxygen therapy and/or nebuliser therapy the resident may be in receipt of and how much, if any, assistance the resident requires with this therapy.
Document the need for oral hygiene to prevent dry mouth/dry lips/dry nose if the resident is on oxygen therapy.
Document if the resident needs any personal and essential items within easy reach e.g., tissues and/or sputum container on bedside table, etc.
Document any medications that may be prescribed to treat/manage the respiratory illness.
Document any need for monitoring the resident’s respiratory illness/dyspnoea.
Document any on-going advice or education the resident may need.
1. NICE Guidance Chronic obstructive pulmonary disease – Management of chronic obstructive pulmonary disease in adults in primary and secondary care Clinical Guidance 12, February 2004 www.nice.org.uk/Guidance/CG12
2. NHS, 2010. Chronic Obstructive Information Pack. Example of Problem/Need: Mary gets breathless on exertion due to her COPD.