What Are Nursing Care Plans?

Think of nursing care plans as the roadmap for a patient’s care. They outline the patient’s current health status, what the nursing team is working towards, and how they’ll track progress. A well-designed care plan helps keep everyone on the same page, ensuring the patient gets the best possible care.

What is Included?

When setting up a care plan we include a lot of detail about the resident including guidance on their cognition, psychological and emotional requirements, how they communicate, their nutritional needs, continence guidance and products, mobility assistance including any mobility equipment required, medication the resident takes, any information about the resident’s sleep habits and their activity requirements such as what kind of activities they can do and what activities they would benefit from.

Following the care plan being set up we also have yearly reviews with the relatives and social workers to ensure that the care plan is up to date and an accurate reflection of the resident’s current needs. The plan is regularly updated with professional visits, relative communication, hospital letters, nurse assessments, medication changes and any other changes in the resident’s condition.

Developing a Nursing Care Plan

Nursing care plans are essential for providing coordinated, patient-centred care. They include an initial assessment of the patient, their diagnosis, the goals of the nursing team, and a way to track progress. While the exact format may vary between healthcare organisations, these core components are always included:

Key Components

• Patient Assessment: This involves a thorough evaluation of the patient’s signs and symptoms, vital signs, and overall health status. Nurses are responsible for gathering and updating this information, although healthcare assistants can assist with tasks like taking vital signs.
• Nursing Diagnosis: Based on the assessment data, the nurse identifies specific nursing diagnoses relevant to the patient’s needs. These are distinct from a medical diagnosis (which is made by a doctor).
• Desired Outcomes and Goals: Here, the nurse outlines what they aim to achieve for the patient. Goals include both short-term improvements (e.g., reduced pain, stabilised vital signs) and longer-term aims (e.g., recovery within a specific timeframe). Goals should always relate directly to the nursing diagnosis.
• Interventions: This section details specific actions the nursing team will take to achieve the goals. Interventions should be evidence-based and tailored to the individual patient.
• Evaluation: The nurse regularly assesses how well the patient is responding to the interventions and whether goals are being met. The care plan is a ‘living document,’ meaning it can be adjusted if needed.

Important Notes:

• Some care plans include a “rationale” section explaining the reasons behind specific interventions. This might be more common if there’s deviation from standard care practices.
• Care plans should be holistic. Consider the patient’s broader needs, such as their mental well-being or preferences for spiritual support services.

Nursing Care Home in Nottinghamshire

At Lowmoor Nursing Home our management team put together care plans for all new residents with input from relatives and social workers to ensure we know each person’s needs inside out. Using this information, we also produce a ‘Snapshot’ for each resident which summarises the information from the care plan and is kept on each unit to make the information easily accessible to care staff.

In the first 14 days at Lowmoor residents have a short-term care plan while we put together the full nursing care plan and will assess new residents during this time, carry out risk assessments, capacity assessments, mobility assessments and more to ensure that the care plan is fully comprehensive.

If you’d like to know more about how we deliver holistic nursing care, please get in touch with Lowmoor Nursing Home on 01623 752288 or email manager@lowmoorcare.com.