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 falling asleep and some nights only sleeps for short periods of time
Goals: To make Mary comfortable in bed and when resting so as to promote sleep and rest.
Care Plan Prompts.
Document Mary’s usually bed time and any other preferences for sleep and rest – include Mary’s usual sleep and rest pattern at night and any rest periods or naps Mary has during the day.
Document the assistance Mary needs with getting ready for bed. This should include what Mary can/cannot do for herself.
Document what staff need to do to assist the resident to promote a good night’s sleep e.g. warm drink, something to eat, bed socks for cold feet, analgesia, night sedation, etc.
Document any needs for access to items, such as call bell etc.
Document Mary’s preferences for comfort needs during the night e.g. light on /off; door ajar etc.
Document the care that is required when Mary wakes up during the night e.g. what can be done to help her to go back to sleep such as giving analgesia, changing incontinence wear, bringing to the toilet, repositioning, giving her something to eat,
etc. Alternatively, document what care is needed if she is unable to go back to sleep e.g. getting her up to sit with staff to have a chat and a cup of tea for an hour or two.
For repositioning and skin condition, if her care needs are already outlined in her skin condition care plan, refer the reader to this. Otherwise record here.
For any incontinence needs, if already outlined in her elimination care plan, refer the reader to this. Otherwise record here.
Document how often the resident is checked at night.