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 is at risk of skin tears because she has dry skin. |
Goals: To reduce the risk of skin tears |
Care Plan Prompts. |
Describe any hazards that increase the risk of skin tears such as manual handling; use of wheelchair etc. Document the description of the resident’s skin from assessment -Remember – any resident that has tissue paper/dry skin is at risk of skin tears – have you ticked this in the Waterlow assessment? Document any methods used to reduce the likelihood of skin tears occurring e.g. moisturiser (most effective method as this increases the elasticity of the skin), protective padding of the residents legs, protective padding of furniture (legs of chairs or tables – be cautious of footrests on wheelchairs). Record any moving and handling considerations such as the need to avoid grasping the resident by the hand or arm – staff should offer up their arm for the resident to grasp instead or grasp resident by more fleshy areas of the body such as upper arm or hip instead of delicate areas such as the forearm, hands or shins or grasp the residents clothing instead of delicate skin or staff avoid using the fingers when moving and handling (use palms of hands instead). Document any preferences the resident has with regard to preventing skin tears. Identify any monitoring / observations required and how often.
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References
- Baranoski, S (2003) How to Prevent and Manage Skin Tears. Advances in Skin and Wound Care. Sept/Oct 2003.
- CREST, (1998) Guidelines for the Prevention and Management of Pressure Sores. www.n-i.nhs.uk/crest
- NHS Modernising Agency (2003) Essence of care. Resident – focused benchmarks for clinical governance.
- National Institute for Clinical Excellence, (2003) Pressure ulcer prevention. www.nice.org.uk
- Health Service Executive, South Eastern Area, (2007) Wound Management Guidelines.
- Health Service Executive (2009) National Best Practice and Evidence Based Guidelines for Wound Management.