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
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
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
Goals often fall into one of the following categories:
Maintenance: To maintain the resident at their current level of ability/functioning.
Prevention: To prevent/ minimise 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:
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
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 (s):
Mary is at risk of adverse effects from warfarin and insulin therapy.
Mary is unable to swallow whole tablets and needs her medicines to be crushed.
Goals: To maximise the benefits to Mary of her medications and reduce any adverse effects associated with Mary’s medication therapy.
Care Plan Prompts.
Document Mary’s needs for taking her medicines – crushing tablets / use of oral suspensions where prescribed.
Document the reason for the need to crush the resident’s medications e.g. physical or psychologically unable to swallow whole
Where the need to crush medications is relating to the residents refusal to take medications, this need should be entered into the
care plan stating that crushing medications is used only as a last resort in a situation where the resident lacks the capacity to
understand the purpose of the medications and risks associated with not taking his/her medications and the medications are
necessary to preserve life or prevent deterioration of the resident (Adapted from Nursing and Midwifery Council, 2007; Commission
for Social Care and Inspection UK, 2007).
Document how the medications will be administered – document Mary’s preferences for taking her medicines e.g. With water,
Document any aids/equipment that are being used for medication management e.g. Spoon.
Identify and document the reason why the resident is taking warfarin and any specific instructions for taking her warfarin.
Document time of the day warfarin is administered.
Document how often the INR is taken.
Document how the resident is monitored for any adverse effects e.g. severe bleeding.
Document the times of the day that the insulin is being administered.
Where the resident has preferred site(s) for administration this should be identified and documented.
Document the times of the day / frequency of blood sugar monitoring.
Where the resident is on a sliding scale, information regarding this should also be entered into the care plan.
Where Mary may decline to take medications, Identify and document any strategies used to gain an understanding as to why she would prefer not to take his/her medications e.g. talking to the resident, identifying if the refusal is associated with the resident experiencing an adverse effect of the medication.
Identify and document any strategies used to help the resident understand the importance of taking his/her medications e.g.
explaining the purpose of the medications.
Document what should be done when the resident declines his/her medications e.g. returning and offering the medications again 30 minutes later.
If declining medications becomes a persistent difficulty, the resident’s general practitioner should be informed to facilitate future planning and consider the need to disguise the medications in her food (disguising medications in food needs to be documented in the care plan as addressed above).
9. United Kingdom Psychiatric Pharmacy Group, (2001) The Administration of Medication in Food or Drink to People Unable to give Consent to or Refuse Treatment Administered in this way. accessed at: http://www.ukppg.org.uk/tablets-in-food.html