Nursing care Plans

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Care plans are:

Care plans are made up of four different parts or stages.

They are:

  • Assessment
  • Planning
  • Implementation
  • Evaluation
  • Remember ….A.P.I.E.

Nursing Assessment

– This is the part of the process where the individual client’s needs are assessed

-  from this assessment we can get a fuller picture of their individual needs

– the assessment should involve all people who have had input into the clients care, this would include:

  • Nurses
  • Relatives
  • Medical staff
  • Social services
  • Speech and language
  • To name just a few
  • This type of assessment is referred to as a “multi-disciplinary assessment”
  • By using all the information that we can we should be able to understand our client better and in a more “holistic” way.

– It is during this stage that we can identify where the client has difficulty and where their problem areas are.

– So it not only helps us to identify their individual problems and needs,

– But it also gives us a full picture of them helping us to understand their life, desires and expectations.

 

– Most importantly you should talk to the client helping to understand their particular individual problems and needs. Trying to.. “look at the world through their eyes.”

– This phase should also start the client carer relationship, which should be based on trust, understanding and empathy.

 

Nursing Planning

– The next stage of this process is the planning stage.

– It is during this stage that we can try to understand the client’s problem and with them look at a way of reducing it.

– The plan must involve all those people who will be using it

– It must involve the client.

– It is always best to look at ways in which we can assist the client to manage themselves as best as they are able to.

– This is called giving them “active support”

– And all staff assisting the client should be aware of the plan.

– But don’t forget that all plans should be:

 

Assessment

  • It must be attainable
  • It must be safe
  • It must have an end goal
  • It must be measurable
  • And they must be realistic.

Nursing Implementation

– This quite simply means putting the plan into progress.

– All that you have discovered about a clients particular problem

– can now help you to reduce it or relieve it completely.

– Using all the resources that you need for example,

-  Outside help, Using any aids required, for example special knives and forks, Plate guards or hoists.

– BUT NO MATTER HOW GOOD A PLAN IS, WITH ARE DEALING WITH UNPREDICTABLE PEOPLE, AND THEIR NEEDS WILL CHANGE.

– So the next phase is very important.

Nursing Evaluation

– This is the phase when we should re-look at the plans and see if they are having the desired effect for example:

– Problem– is mobility

– Plan is– refer to client for walking aid.

– Implementation—Zimmer frame received, /No reply

– Evaluation. May mean re-try as possibly in above scenario or to move on to the next plan for that problem (“Chaining”)

– For Example—Teaching the client how to use a Zimmer frame, at first with assistance.

What do we assess?

– We assess looking back to our activities of daily living, and more that is:

– (Group to look again at the ADLs)

– What are they?

  • Communication
  • Personal hygiene
  • Dressing
  • Sleeping
  • Motivation
  • Mobility
  • Elimination
  • Risk
  • Eating and drinking
  • Breathing
  • Memory
  • Orientation
  • Behaviour
  • Loss and change
  • Sexuality
  • Social relationships
  • Personal and spiritual fulfilment
  • Cognition
  • And more

Overview

When a new client come in, they should be Assessed for any problems relating to the above.

If they have problems in these areas then a care plan should be drawn up to guide them to a goal in order to either:

Resolve the problem

Or

To find a way of managing with it, without the problem interfering with their daily lives.

 

Example one

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Example two

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