Writing Your Care Plan. Mood and Behaviour:
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 / reduce the likelihood of something happening eg physical aggression.
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 can get physically aggressive towards staff when they try to provide care.
Staff are at risk of injury when Mary becomes physically aggressive.
Goals: To meet Mary’s unmet needs and reduce episodes of physical aggression towards staff.
Care Plan Prompts.
Describe how the problem manifests itself / what behaviours Mary displays e.g. what happens when staff approach Mary. Be specific by
describing the actual behaviour e.g. spitting, biting, kicking, shouting, swearing, etc. rather than using the words agitated or aggressive.
Document Mary’s level of ability regarding the behaviours – can she let staff know if she doesn’t understand what they are doing, eg
verbal/non-verbal cues that staff can be alerted to so as to meet her needs for reassurance and explanation of what care they are going
Identify any known causes/triggers for the behaviour, such as if staff approach in a particular way or if Mary doesn’t understand what
staff are doing. If unknown and ABC monitoring is in place, state same and update the care plan when this has been completed.
Document anything that staff should avoid doing where possible to avoid triggering the behaviour
Document any interventions needed to meet Mary’s needs for explanation prior to undertaking care activities eg. Use of pictures to
explain what staff are about to do. Also document any distraction techniques that may help prevent or reduce the behaviour e.g. warm
friendly approach, chatting, giving her items to hold, etc.
Document any known likes/ dislikes Mary has for providing care – if these are outlined in other domains eg. Personal hygiene, refer to the
care plan in that domain.
Document any known interventions that can be used to help Mary when she displays the behaviours. This may include returning at a
later stage to carry out the care activity.
Document the involvement of psychiatry of old age and any instructions given for Mary’s care.
Document any need for monitoring Mary’s response to care and how this is to be recorded and reported.