Care Plans

Every resident in residential care needs a personalised care plan that meets their individual health and wellbeing needs.

They are important as they:

• Let everyone that is caring for the resident know what they need to do so the resident receives consistent, quality care and remains comfortable.

• And help any staff member understand “Who is this resident, what do they need, and how do we support them safely and respectfully?”

Care plans should be created:

• In collaboration with the resident and/or their family/whānau.

• The resident’s holistic needs (physical, mental, spiritual and social) also need to be assessed.

Tips for writing care plans:

• Write clearly and simply

• Use objective language

• Be specific

• Include measurable actions

• Update promptly

• Involve resident and whānau

Good care plans include:

• Identified problems that the resident experiences

• Causes and/or background of the problem

• Realistic goals/aims to manage the problem

• Interventions, both pharmacological and non-pharmacological, to meet the goal/aim

• What to do in a crisis/emergency

• Regular reviews/evaluation of the plan, including the date

Care plan examples:

Example one:

Problem: Dyspnoea/breathlessness on exertion

Related to: Advanced COPD

Aim: For resident to be able to assist with their own ADLs to maintain independence, attend activities in the lounge

Triggers:

• Mobilising

• Showering

• Infection

Non-pharmacological strategies:

• Positioning upright, rectangular breathing – breathe in for two counts, breathe out for four counts

• Use a hand held fan or have a window open so air circulates

• Taking time to complete ADLs

• Timing activity to take place after dyspnoea medications have had time to take effect

• Ensuring window open when showering

• Use of aids like low walking frame to facilitate rest during mobilising

• Provide calm environment and reassurance during dyspnoea episodes

Pharmacological interventions:

• Regular inhalers

• PRN Morphine elixir

• PRN Midazolam nasal spray for associated anxiety

• Encourage infection prevention e.g. flu vaccination

Example two:

Problem: Constipation

Related to: use of opioids to manage dyspnoea and pain

Aim: BO every 1-2 days

Non-pharmacological strategies:

• Encourage fluids and fibrous foods

• Monitor bowel motion frequency and consistency

Pharmacological interventions:

• Administer regular laxatives as prescribed

• Administer PRN laxatives if resident has not had a bowel motion from day 2 onwards until bowels open

• Administer PRN enema if impaction is diagnosed by performing a PR examination

Other helpful tips:

• It can be useful to have a resource file with different care plans so they can be easily accessed and adapted for a new resident. This may be helpful for newer nurses who are not quite sure where to start when developing a care plan for a certain symptom or physical need.

• Reviewing specific care plans as a team is also helpful especially care plans for complex wounds so there is consistency between shifts but also so you can learn from each other.

• Also check out the Frailty Care Guidelines as these can also guide the development of a care plan.