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 unable to perform oral hygiene independently because of her left sided weakness and cognitive impairment.
Mary has tooth decay and bleeding gums in her two back molars.
Goals: To improve Mary’s dental status and prevent any further deterioration in her oral and dental status.
Care Plan Prompts.
Arrange a review by /liaise with Mary’s dentist.
Identify and describe if she has natural teeth (where – top and/or bottom) and/or wears dentures (top and/or bottom).
Identify and document frequency of oral hygiene to be performed – times of the day.
Identify and describe any assistance Mary may need with performing oral hygiene. This might include for example prompting, supervision,
assistance of one, etc. The care plan should also include any abilities relating to oral / dental care that Mary has.
Identify and describe any methods used to promote/maintain independence e.g. hand over hand technique.
Describe any preferences Mary has for oral hygiene care, such as at the sink, with a basin and fresh water, etc.
If Mary wears dentures, describe how the dentures are cleaned.
Where she does not use a toothbrush and toothpaste for oral hygiene, describe how oral hygiene is carried out.
Describe how, if any, Mary’s dental status affects her on a day to day basis e.g. affects her ability to chew, pain, unable to wear dentures,
Document how these day to day problems will be addressed.
Identify and describe any specific oral hygiene needs she may have e.g. any prescribed medications or analgesia used to treat oral/dental disease.
Identify and document frequency of oral hygiene to be carried out.
Document any recommendations and/or treatments as per dentist or general practitioner and how these recommendations affect Mary’s care on a day to day basis.
Identify and document how the problem will be monitored for signs of improvement or deterioration.
30/09/2012 at http://rnao.ca/sites/rnao-ca/files/Oral_Health__Nursing_Assessment_and_Interventions.pdf