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/ 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.
Care Plan:
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 of Problem(s): Mary needs assistance with eating and drinking
Mary requires a modified textured diet and fluids due to swallowing difficulty related to CVA.
Mary has a poor appetite, is underweight and has a MUST Score of 1 due to CVA.
Goals: To maintain Mary’s nutritional status and prevent deterioration.
Care Plan Prompts.
Describe the level of assistance the resident requires when eating and drinking.
If not already documented, document any specific aids that are used when eating or drinking e.g. beaker, teaspoon, etc.
Document likes / dislikes for food, drink, preferred place to eat, preferred portion sizes, etc.
Document any verbal assistance the resident may require e.g. informing the resident of what food is on the plate.
Document how the resident can inform the staff member assisting with eating or drinking that they have had sufficient e.g.
moves head away, wont reo-open mouth, pushes person assisting away, etc.
Document any specific needs the resident may have e.g. positioning, taking time, prompting to swallow, etc.
Where the resident requires modified food or fluids document the specific texture e.g. texture B minced and moist food or
grade 2 mildly thick fluids.
Where there are any specific recommendations from the speech and language therapist or dietician, these should be
recorded. Consider and record how these will affect the resident on a day to day basis e.g. prescribed ensure twice daily as
per dieticians recommendations and likes vanilla flavour only, prefers to take them at 11:30hrs and 19:30hrs.
If MUST Score 1 or greater, place the resident on a day food diary to assess and monitor the resident’s nutritional intake document that the resident is on a food diary.
Where appropriate consider developing a meal plan for the resident particularly if the resident prefers not to eat at scheduled meal times – small frequent meals may be more suitable – document that the resident is on a meal plan.
If Must score1 or greater, monitor weight weekly and document that this is occurring..
Where food is being fortified, document what food and how it is being fortified e.g. adding butter to potatoes, adding cream to
porridge, adding cream cheese to soup, etc.
Identify and document any methods of encouraging the resident to eat or drink.
Document any additional snacks that the resident may tolerate to increase calorie intake e.g. cheese, chocolate, etc.
Document how the resident’s condition will be monitored and frequency of monitoring, e.g. weekly weight and MUST scoring and review in 4 weeks.
Where family members can be involved, document their involvement.
References.
- International Council of Nurses, (2004) Nutrition and Older People. Nursing Matters Fact Sheet. www.icn.ch/matters_nutrition_olderpeople
- Health Information and Quality Authority (2009) National Quality Standards for Residential Care Settings for Older People.
- Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People Regulations 2009 amended).
- Health Information and Quality Authority (2013) Regulatory Guidance for Residential Services for Older People: Food and Nutrition Requirements
- NHS Modernising Agency (2003) Essence of care. Patient – focused benchmarks for clinical governance.
- NHS Scotland Nursing and Midwifery Planning and Development Unit, 2002. Best Practice Statement. Nutrition for physically frail older people. Nursing and
Midwifery Planning and Development Unit. Edinburgh.
- Midland Health Board Department of Older Persons, (2004) Standard Operating Procedure for Appropriate use of Oral Nutritional Supplements in long stay care.
Accessed 19/02/2008 @ www.mhb.ie
- Rafferty, S. et al (2000) Recommendations for a national food and nutrition policy for older people. Food Safety Authority of Ireland. Dublin.
- Midland Health Board, (2007) Standard Operating Procedure: Placement and Administration of Subcutaneous Infusion. Accessed 19/02/2008 @ www.mhb.ie
- Midland Health Board, (2005) Standard Operating Procedure: Care of the Older Person on Percutaneous Endoscopic Gastrostomy Tube (PEG) Feeding. Accessed
19/02/2008 @ www.mhb.ie
- NHS Scotland Nursing and Midwifery Planning and Development Unit,(2002). Best Practice Statement: Nutrition assessment and referral in the care of adults in
hospital. Nursing and Midwifery Planning and Development Unit. Edinburgh.
- Clinical Resource Efficiency Support Team CREST (2004) Guidelines for the Management of Enteral Tube Feeding in Adults. CREST Secretariat, Stormont.
- National Institute for Health and Clinical Excellence NICE, (2006). Nutrition Support in Adults : oral support, enetral tube feeding and parenteral nutrition.
Accessed 11/02/2008 @ www.nice.org.uk
- American Medical Directors Association, (2007) Altered nutritional status clinical guideline. Accessed 13/02/2008 @ www.guideline.gov
- Hartford Institute for Geriatric Nursing, (2008) Nursing Standard of Practice Protocol: Assessment and Management of Mealtime difficulties. Accessed11/02/2008
@ http://www.consultgerirn.org/topics/mealtime_difficulties/want_to_know_more
- Hartford Institute for Geriatric Nursing, (2008) Nursing Standard of Practice Protocol: Nutrition in Ageing. Accessed 11/02/2008 @
http://www.consultgerirn.org/topics/nutrition_in_the_elderly/want_to_know_more Hartford Institute for Geriatric Nursing, (2008) Nursing Standard of Practice
Protocol: Hydration Management accessed 12/02/2008 @ http://www.consultgerirn.org/topics/hydration_management/want_to_know_more
- Joanna Briggs Institute, (200) Identification and Nursing management of Dysphagia in Adults with Neurological Impairment. Vol. 4(2) 2000.