How To Write a Nursing Care Plan
If you’re considering moving into a nursing home, you’re likely thinking about how you can ensure all your wishes are met. The good news is, most good care homes will operate with person-centred care in mind and will take your preferences and unique needs into account. A nursing care plan is how nurses ensure that your physical, metal and spiritual health is being looked after in the best possible way. In this blog, we’ll explore what a nursing care plan is, why they are important and how to write yours.
What is a nursing care plan?
A nursing care plan is a document that sets out a person's needs and the ways in which they will be met. They contain details about the individual's physical health, diagnosis and symptoms, as well as their preferences, values and emotional needs. This information is to help care home nurses ensure that residents’ wishes are being met and that the individual is at the heart of every aspect of their own healthcare.
Care plans are referred to by the wider healthcare team, including the person’s family, care home nurses, GPs and other healthcare providers. This allows each person involved with the individuals care to work collaboratively, ensuring everyone has the same information and are aware of treatment preferences.
When moving into a care home, the expert nurses will help you create your plan and will use their skills and knowledge to help you direct your own care. The nurses will get to know your personality and interests alongside your condition; this is known as person-centred care. This holistic approach to nursing care also keeps in mind your emotional, physical and spiritual needs.
Your care plan is also place where you can set long and short term goals relating to your health and life in care. Your current condition will be assessed in your care plan and will be built upon and measured over time. Nursing care plans are reviewed regularly and are flexible to be adjusted as your condition or preferences change.
In summary, nursing care plans are a record of actions that should be taken to ensure person-centred care.
Why are nursing care plans important?
One of the primary benefits of a having nursing care plan is the promotion of emotional wellbeing. Care plans should ensure you feel heard, respected, and supported, which can reduce anxiety and build trust between those receiving care and healthcare professionals. Nursing care plans also encourage independence by identifying what you can do for yourself and setting realistic goals that support autonomy, dignity, and confidence.
Another significant advantage is tailored and consistent healthcare; care plans are personalised to meet your specific needs while providing a clear framework that ensures clear communication between all healthcare staff.
Additionally, nursing care plans adopt a holistic approach, considering not only physical health but also psychological, social, cultural, and spiritual needs, leading to more comprehensive and effective care. Family involvement is also strengthened through nursing care plans, as loved ones are informed and engaged in decision-making, enabling them to provide appropriate support and reassurance. Consequently, this results in improved safeguarding by identifying potential risks and outlining preventative measures to protect more vulnerable individuals.
How to write a nursing care plan
When moving into a high-quality nursing home, a nurse will work with you to create your nursing care plan. Therefore, it’s a good idea to think about what you might want recorded in your care plan, and have a basic understanding of how they are written. Nurses use five steps to create a care plan, which are: Assessment, Diagnosis, Planning, Implementation and Evaluation.
Assessment & Diagnosis
The first step in creating your nursing care plan is an assessment by a healthcare professional. During this assessment, physical health data will be recorded as well as verbal statements. While a nurse will not be able to diagnose you with a condition themselves, they will notice changes (both positive and negative) in your symptoms, will make a note of these in your care plan, and judge whether you need reassessing. This also allows your GP or other healthcare specialists to adjust your diagnosis or medical treatment if needed.
Your nurse can also help prioritise which symptoms or conditions to treat first based on your physical health and preferences. Furthermore, preferences of medical treatments will be noted, for example, if you have signed a DNR form, do not want certain procedures, and of course, if you have any allergies.
Care plans will start from a basic place to ensure the minimum criteria of care is met, and will be built up from there to create the best possible outcome. Psychological factors will also be assessed, such as your mental state and how best to support your emotional health.
Planning & Setting Goals
A large part of a nursing care plan is having a record of your values and preferences. This can include favoured medical treatments as mentioned before, but can also relate to personal care, nutrition, sleep, your interests and hobbies.
Using a holistic approach to care planning also takes into account environmental factors, for example, making your room comfortable, warm and as relaxing as possible. All-inclusive homes will also be able to offer other therapeutic services for wellbeing, including a range of mentally stimulating activities, access to outdoor spaces, and the opportunity to socialise. Great care homes will take into account the preferences of every resident, and adjust their dining menus, activity plans and social calendar accordingly.
Another aspect of your care plan will also recommend communication methods. This could be as simple as the tone of voice or type of language nurses use with you, but could be more complex for residents who may be non-verbal, hard of hearing, communicate in non-traditional ways, or even navigating a language barrier. Whatever your situation, a nursing care plan should ensure that you are made aware of your own health and treatment in a way that you are able to comprehend and understand. This communication should be extended to your family or loved ones with your permission.
Intervention planning is a process that includes proposals from your healthcare team about potential treatments, risk management or preventative measures. Complementary therapies can also be suggested such as aromatherapy or pet therapy, which come included in some luxury care homes. It is important that nurses are aware of how you would want any potential emergency or incident to be dealt with. The planning section of your care plan also suggests what you can do for your own health and outlines anything you may need less assistance with. This will help maintain independence and dignity in your care.
An important part of a nursing care plan is goal setting. SMART goals are the best way to set tangible objectives; this means your goals should be: Specific, Measurable, Achievable, Relevant, and Time-bound. Your nurse will help you set your goals, track them and adjust parameters if necessary. An example of a SMART goal could be, “I want to be able to walk the length of my bedroom with a walker within two weeks.” Your goals should be made based on what is important to you, whether that’s hitting a milestone with your physical health, or being able to return to a hobby you had to give up due to your health. Having something to aim for is not only great for morale and motivation, it can boost mental health, self esteem and provide a sense of achievement. Nurse will also work with you to make decisions to help you achieve these goals.
Implementation and Evaluation
Nursing care plans should be regularly updated and reviewed. This includes changes in physical and psychological symptoms, needs, diagnosis and preferences. It’s important that you speak up if you are unhappy with any part of your care plan, whether you think it is not being followed properly or simply if you change your mind about any details.
Remember, person-centred care is designed to put you at the centre of your care to ensure the highest possible quality of life.
Nursing home in Edinburgh
Here at Struan Lodge Care Home in Edinburgh, we recognise and celebrate every individual in our care. Our exemplary nursing care is tailored to the needs to each resident to ensure they feel safe, valued and well-cared for. Our dedicated team is on hand 24/7 to offer support for complex medical needs, including palliative care and specialist dementia care. Contact our friendly team today to discuss how we can create a nursing care plan centred around you and your needs.
