Holly F. Sox, RN, BSN, RAC-CT - Clinical Editor, Careplans.com
Care planning is an essential part of healthcare, but is often misunderstood or regarded as a waste of time. Without a specific document delineating the plan of care, important issues are likely to be neglected. Care planning provides a "road map" of sorts, to guide all who are involved with a patient/resident's care. The care plan has long been associated with nursing, and many people believe (inaccurately, in my opinion) that is the sole domain of nurses. This view is damaging to all members of the interdisciplinary team, as it shortchanges the non-nursing contributors while overloading the nursing staff. To be effective and comprehensive, the care planning process must involve all disciplines that are involved in the care of this patient/resident.
The first step in care planning is accurate and comprehensive assessment. In the acute care setting, a thorough admission nursing assessment should be followed by regular reassessments as often as the patient's status demands. In the long- term care setting, the MDS (Minimum Data Set) is the starting point for assessment. Home health utilizes the OASIS assessment. Other settings will have established protocols for initial assessments and ongoing reevaluation.
Once the initial assessment is completed, a problem list should be generated. This may be as simple as a list of medical diagnoses, or may involve working through the RAP (Resident Assessment Protocol) process associated with the MDS. The "problem" list may actually include patient/resident strengths as well as family/relationship problems, which are affecting the person's overall well-being.
Once the problem list is complete, look at each problem and ask the question, "Will this problem get better?" (Or, "Can we make this problem better?") If the answer is yes, then your goal will be for the problem to resolve or show signs of improvement within the review period. In the acute setting, the review period may be as short as next shift, next day or next week. In the long-term or home health setting, the review period will likely be longer. In any case, the goal should be specific, measurable and attainable. Do not write a goal that a stage 4 pressure ulcer "will be improved by next week." This is not specific or measurable, and most likely not attainable. A better goal statement would be for "stage 4 pressure ulcer to improve to less than full thickness and length/width to __X__cm in the next 90 days." The approaches (or interventions) should also be measurable and realistic, and should be documented elsewhere in the record when performed. An example of a problem that will improve would be self-care deficit related to hip fracture. With rehab, this problem is likely to resolve.
If the problem is not likely to improve or resolve, then ask the question, "Can we keep this from getting any worse, or developing complications?" Examples of this type of problem would be diabetes or congestive heart failure. These problems are not going to get better, but we can generally intervene and prevent or minimize complications or decline. Your goal statements should again be specific and measurable. "Will maintain blood sugar within acceptable range as determined by MD", or "Will maintain SBP >100 and <170, DBP>50 and <100, Pulse >60 and <100"
If the problem is not likely to improve, and deterioration is inevitable, then the last question will be, "What can we do to provide optimal quality of life, comfort and dignity for this person?" Examples of this would include cognitive loss related to Alzheimer's disease, nutritional problems associated with a terminal condition. These are problems that are going to deteriorate in the natural progression of the disease process. We may be able to delay some of the complications or problems, for example, by administering certain medications or treatments. But decline is inevitable in the long run. The goal, therefore, becomes providing optimal quality of life within the limitations of the disease process. For a dementia patient, I may state a goal that s/he "will maintain the ability to recognize family and participate in simple (yes/no) decision making daily through the review date." For unavoidable nutritional problems, the goal may be for s/he to "consume food/fluids as desired without GI distress daily through review date."
For all problems, interventions/approaches may be physician ordered, facility protocol or accepted standard practices. Facility policy will determine how specific the written approaches will be. Some facilities may require specific medications, doses, and times, etc. to be spelled out in the care plan, while others may endorse the use of approaches such as: "Administer medications as ordered. See MAR, MD orders for current orders."
The care planning process is never truly completed until the patient/resident is discharged from the current care setting or is deceased. The care plan needs to be fluid and changeable, as patient/resident status changes. Periodic scheduled reevaluation must take place, with changes being made as needed. Unscheduled updates should also be made as condition warrants. When a problem has resolved, that problem can be completed. If the person has had a major change in a problem area that results in changes in goals and approaches, it may be easiest to resolve the problem and enter an entirely new problem, goal(s) and approaches, rather than making many changes to the existing problem.
Remember that the ultimate purpose of the care plan is to guide all who are involved in the care of this person to provide the appropriate treatment in order to ensure the optimal outcome during his/her stay in our healthcare setting. A caregiver unfamiliar with the patient/resident should be able to find all the information needed to care for this person in the care plan.