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 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).
Example:
Example of Problem/Need: Mary has difficulty with speech and making herself understood due to her CVA.
Goals: To improve Mary’s ability to communicate with others.
Care Plan Prompts.
- Describe how this affects Mary on a daily basis e.g. Unable to communicate needs; frustration, anxiety etc.
- Document any non-verbal methods of communication Mary may have e.g., pointing, moaning, groaning, restlessness, body or facial movement, etc and indicate what these non-verbal communications may mean (if known) e.g. when resident becomes restless this may indicate the his/her incontinence wear needs to be changed or when resident moans or groans this may mean he/she has pain.
- Document any specific methods used when communicating with Mary e.g., using short simple sentences, giving one piece of information at a time, asking questions that require a yes/no response.
- Document any likes and preferences or dislikes Mary may have for communication e.g., Staff positioned at eye level, not rushing etc.
- Document any aids Mary may use to communicate e.g., pen & paper, picture cards, etc.
Document any other healthcare professionals that may be involved e.g., speech therapist and how this influences daily care.