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): The resident has pain chronic pain in her right shoulder, due to arthritis
Goals: To reduce Mary’s pain to a level that is acceptable to her.
Care Plan Prompts.
Where the resident is able to verbally communicate the presence of pain, the Brief Pain Inventory should be completed on admission, every three months, where there is a change in the resident’s condition or pain or where the resident is complaining of a new pain e.g. development of a wound or skin tear, following a fall, fracture, etc.
Where the resident is unable to verbally communicate the presence of pain the Abbey pain Scale should be completed.
NB. The Abbey Pain Scale should be completed on all residents with moderate to severe dementia who cannot clearly verbalise the presence of pain, Complete on admission, every three months or if there is a change in the residents condition (Kimberley et al, 2008).
NB. Residents with moderate to severe dementia should receive regular analgesia not as required/PRN (Cunningham, 2006).
NB. Nursing staff should predict pain for those residents with dementia – consider the need for analgesia prior to carrying out nursing care e.g. washing and dressing, renewing a wound dressing, etc.
The care plan should identify any specific non – verbal signs of pain that the resident displays (if not already identified in another section of the care plan e.g. abilities).
Identify and document any aggravating factors that is, what brings on or makes the pain worse.
Identify and document what helps to ease the pain, include any non –pharmacological or complementary therapies the resident may be using to help relieve pain (if not already addressed in another section of the care plan).
Where possible describe the type of pain the resident experiences e.g. dull ache, burning, throbbing, etc. and the intensity of the pain.
The care plan should include what pain relief the resident is receiving and when this should be administered.
Identify and document in the care plan how the effectiveness of the pain relief will be monitored e.g. the nurse will return 30 minutes following the administration of analgesia to ask the resident about his her pain or to observe if any non-verbal signs e.g. moaning, grimacing etc. have resolved.
Identify and document any comfort measures that may be needed to help the resident cope with his/her pain e.g. emotional or physical support.