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 has difficulty interacting with others due her inability to form sentences related to dementia.
Goals: To promote psychosocial well-being and prevent Mary for experiencing isolation and boredom.
Care Plan Prompts.
Document in the care plan how Mary likes to spend her free time – what activities can she participate in and what interests does she have – this should include one to one, self-directed or/and group activities.
Where applicable, Marys care plan should specify what type of music she likes e.g. classical, or tv programmes she likes e.g. the RTE news
and nature programmes, and or reading material she enjoys e.g. Irish Times newspaper, rather than just stating listening to music, watching tv, reading.
Document any assistance staff need to provide Mary so that they can carry out activities of interest, e.g. prompting, reminding, setting things up for her, etc.
Document any important people in Mary’s life and how often they visit – include any activities they do with Mary e.g. chat, reading,
taking her out around the grounds, bringing her out of the day , etc.
Where Mary prefers not to or is unable to attend scheduled activities, document any other activities that can be carried out with Mary to prevent isolation and boredom and how often these occur e.g. hand massage, applying nail varnish, music therapy, etc.
Where Mary is experiencing difficulties with coming to terms with or expressed any concerns about being in long term care, document any interventions that are required by staff to help Mary with this need.
Because Mary has dementia and poor short term memory, the care plan should document any long past events/memories that Mary may still remember e.g. being a teacher, holiday to France, where she grew up, etc., so that staff know what suitable topics they can chat to Mary about and encourage participation.
Care Settings for Older People in Ireland.
behaviours that challenge in residential aged care facilities. NSW Department of Health,
Sydney accessed at www.nswhealth.org.au
Times. Vol 11(3).
Environment. Standard Operating Procedure.
Nursing Standard. Vol. 20 (47) pp. 42-45.
Clinical Guideline. Accessed at www.sign.ac.uk.
Training Programme. CPI. England
Behaviors NHS Trust:England
Dublin. An Bord Altranais.