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Maintaining a Care
Plan
Care Plan…
•Care plans (or support plans) are created for
individuals in care homes.
•A care and support plan will clearly lay out
(පැහැදිලිව ලෑස්තියි)
•The level of support a person needs,
•how the support will be given
•what the aims and goals of the care are
•any other necessary details.
What is a care plan
•A care plan is a form where you can summarize
a person’s health conditions, specific care
needs, and current treatments.
•The care plan should outline what needs to be
done to manage the care needs.(කළ යුතු දේ
දෙනහැර දක්වන්න)
What is a care plan…
• It can help organize and prioritize caregiving
activities. (රැකවරණය සංවිධානය කිරීම සහ ප්‍රමුඛත්වය
දීම)
•A care plan can give you a sense of control and
confidence (පාලනය සහ විශ්වාසය)when managing
caregiving tasks
•help assure you that the care recipient’s needs are
being met.(ස්ත්කාර ලබන්නාගේ අවශ්‍යතා ස්පුරාලන
බවට ස්හික වීමට උදවු කරන්න.)
What is a care plan…
•Having a care plan can help you as a caregiver,
especially if there are multiple caregivers, to aid
with transitions and.(ස්ංක්‍රාන්ි ස්ඳහා උපකාර
කිරීම),
•to have all important information in one
place.(සියලුම වැදගත් ගතාරතුරු එක තැනක තබා
ගන්න)
What is a care plan…
•A care plan documents the process of identifying a
patient’s needs(ක්ියාවලිය දේඛනෙත කරයි)
• facilitating holistic care, typically according to a
five-step framework.(පිපූර්ණ සත්කාර සඳහා පහසුකම්
සැලසීම කරයි)
• A care plan ensures collaboration of care givers
with other healthcare providers.(සහදයෝගීතාව
සහතික කරයි)
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Maintaining a Care Plan .pdf

  • 2. Care Plan… •Care plans (or support plans) are created for individuals in care homes. •A care and support plan will clearly lay out (පැහැදිලිව ලෑස්තියි) •The level of support a person needs, •how the support will be given •what the aims and goals of the care are •any other necessary details.
  • 3. What is a care plan •A care plan is a form where you can summarize a person’s health conditions, specific care needs, and current treatments. •The care plan should outline what needs to be done to manage the care needs.(කළ යුතු දේ දෙනහැර දක්වන්න)
  • 4. What is a care plan… • It can help organize and prioritize caregiving activities. (රැකවරණය සංවිධානය කිරීම සහ ප්‍රමුඛත්වය දීම) •A care plan can give you a sense of control and confidence (පාලනය සහ විශ්වාසය)when managing caregiving tasks •help assure you that the care recipient’s needs are being met.(ස්ත්කාර ලබන්නාගේ අවශ්‍යතා ස්පුරාලන බවට ස්හික වීමට උදවු කරන්න.)
  • 5. What is a care plan… •Having a care plan can help you as a caregiver, especially if there are multiple caregivers, to aid with transitions and.(ස්ංක්‍රාන්ි ස්ඳහා උපකාර කිරීම), •to have all important information in one place.(සියලුම වැදගත් ගතාරතුරු එක තැනක තබා ගන්න)
  • 6. What is a care plan… •A care plan documents the process of identifying a patient’s needs(ක්ියාවලිය දේඛනෙත කරයි) • facilitating holistic care, typically according to a five-step framework.(පිපූර්ණ සත්කාර සඳහා පහසුකම් සැලසීම කරයි) • A care plan ensures collaboration of care givers with other healthcare providers.(සහදයෝගීතාව සහතික කරයි)
  • 8. Why we need to have a care plan •To identify the client’s health care status •To identify the client’s actual and potential health problems •To establish the care for identified needs(හඳුනාෙත් අවශ්යතා සඳහා රැකවරණය ස්ථාපිත කිරීම)
  • 9. Why we need to have a care plan… •To document the patient’s needs and wants, as well as the interventions (or implementations) planned to meet these needs. • As part of the patient’s health record • To use to establish continuity of care
  • 10. What are the benefits of a care plan? •Reduce emergency room visits and hospitalizations •Improve overall medical management for people with a chronic health condition, like Alzheimer’s disease. •Retain quality of life (ජීවන තත්ත්වය පවත්වා ගන්න) •independence for the care recipient.
  • 11. What are the benefits … •Help care givers to focus on patients in a holistic, big-picture •To Provide individualized unique care •Balance both your life and that of the person to whom you are providing care(ඔගේ ජීවිතය ස්හ ඔබ රැකවරණය ස්පයන පුද්ගලයාගේ ජීවිතය ගදකම ස්මබර කරන්න)
  • 12. What are the benefits … •To better understand their care needs to family members and loved ones , health conditions and how they can offer additional support. •Ensure that the care seeker consistently receives the right level of care
  • 13. What are the benefits … •Any changes to the resident’s health condition will be carefully noted in their health record. •Allows a team of care givers, nurses as well as physicians, assistants, and other care providers to access the same information (එකම ගතාරතුරු ගවත ප්රගේශ්‍ වීමට), share opinions, •collaborate to provide the best possible care for the patient.(රැකවරණය සැපයීමට සහදයෝෙදයන් කටයුතු කරන්න)
  • 14. What are the benefits … • A care plan helps care team members organize aspects of patient care according to a timeline.(කාලරාමුවකට අනුව දරෝගී සත්කාරක අංශයන් සංවිධානය කරන්න) • It’s also a tool for them to think critically(ඔවුන්ට ගරෝගියාගේ ශ්‍ාරීරික, මගනෝවිදයාත්මක, ස්මාජීය ස්හ අධ්‍යාත්ික රැකවරණය ස්ඳහා ස්හාය වන ආකාරගයන් පරිපූර්ණ ගලස් විශ්‍තගේෂණාත්මකව සිතීමට ගමවලමක් ගලස් ) and holistically in a way that supports the patient’s physical, psychological, social, and spiritual care.
  • 15. What are the benefits … •For patients, having clear goals to achieve will make them more involved in their treatment and recovery.(දරෝගීන් සඳහා, සාක්ෂාත් කර ෙැනීම සඳහා පැහැදිලි ඉලක්ක තිබීම) •Ensuring that you receive the same care regardless of which care worker is on duty(කුමන දස්වකදයකු රාජකාිදේ දයදී සිටියත් ඔබට එම දස්වය ලැදබන බව සහතික කිරීම) •Ensuring that the care you receive is recorded
  • 16. What should be included in the care plan •Personal Information (name, date of birth, contact information) •Health conditions, medical history •Medicines, dosages, and when/how given •history of injuries and illness
  • 17. What should be included in the care plan •Health care providers with contact information •Health insurance information •Emergency Contacts, family information •Employment history •Culture and religion to give carers and staff
  • 18. What should be included … •Goals and aspirations: What the care seeker wants to get out of their care(ඉලක්ක සහ අභිලාෂයන්) •The care seeker’s hobbies, likes, dislikes and preferences on meals and daily routine •Who is paying for the care: The care seeker’s personal budget(පුද්ගලික අයවැය) •Payment details
  • 19. What should be included … •Details of key dates and life events (this is particularly important for care seekers with dementia) •Equipment, adaptations, or specific medical care needed •Details of continuity of care •Details of end of life care, if required (this is often offered in a palliative care home)
  • 20. Components of the care plan •Assessment •Problem identification •Planning for resolving the problem •Implementation •Evaluation
  • 21. 1. Assessment •The clients’ needs are assessed (ගනුගදනුකරුවන්ගේ අවශ්‍තයතා තක්ගස්තරු කරනු ලැගේ) •care giver can get a fuller picture of their individual needs
  • 22. 1. Assessment… •The assessment should involve all people who have involve the client’s care. •A needs assessment will look at clients’ unique care requirements and the level of support need, as well as the type of care home that would best suit (ෙනුදදනුකරුවන්දේ අේවිතීය සත්කාර අවශයතා දදස බලනු ඇත)
  • 23. 1. Assessment… •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’ •start the client –carer relationship which should be based on trust, understanding and empathy
  • 24. How we can obtain the patient’s data •By asking •Doing physical examination •Reviewing client’s records •Consulting supportive people •Consulting health personals
  • 25. Type of data •Subjective data (symptoms) •Obtain directly from the client by talking with him •Eg- itching, pain, worry, hungry •Information supply by the family members, significant others or other health professionals
  • 26. •Objective data (signs) •Detect by observing as it can be seen, heard, felt or smelled •Gain physical examination and investigation test •Eg- blood pressure, body temperature, swelling, low heamoglobin
  • 28. Physiological needs •The need to breath •The need to drink •The need to eat •The need to dispose bodily waste
  • 29. Safety needs •Physical safety •Security of employment •Family security •Security of resources •Health security
  • 30. Love and belonging need •Friendship •Sexual intimacy •Support and communication with family
  • 34. Esteem needs •Confidence •Personal achievement •Respect of others •Attaining respect by others
  • 39. Self actualization •Creativity(නිර්මාණශීලීත්වය) •Appreciate the life(ජීවිතය අෙය කරන්න) •Feel closeness to others(අන් අයට සමීප බවක් දැදන්) •Motivated by values (වටිනාකම් වලින් දපලඹී ඇත)
  • 43. motivate seniors to adopt healthy behaviors
  • 44. What do we assess? •Activities of daily living •Gather data about the patient’s vital signs •physical complaints
  • 45. What do we assess… •Visible body condition •Medical history •Current body functioning.
  • 46. ADL •Activities of daily living refer to the basic skills needed to properly care for oneself and meet one’s physical needs in six areas: •eating, dressing, bathing, toileting, continence and mobility
  • 47. ADL… •A person may be totally independent, require minimal or moderate assistance, or be completely dependent on another person in each area. •Health conditions that affect musculoskeletal, neurological, circulatory or sensory systems can also affect a senior’s ability to perform ADLs.
  • 48. ADL… •Why daily care important •Unmet needs for help with activities of daily living can lead to malnutrition, poor personal hygiene, isolation, illnesses like urinary tract infections (UTIs) and falls.
  • 49. 2. Identification of problems •The needs to be fulfill immediately •High priority needs(ඉහළ ප්රමුඛතාවයක්) •The need to be fulfill little be late •Medium priority needs •The needs to be fulfill later •Low priority needs
  • 50. 3. Planning • 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(එය භාවිතා කරන සියලුම පුද්ගලයින් ස්ම්බන්ධ්‍ කරන්න) •It must involve the client •Write the nursing interventions
  • 51. 3. Planning… •look at ways in which we can assist the client to manage themselves as best as they are able to(දස්වාදායකයාට තමන්ට හැකි අයුින් තමන්ව කළමනාකරණය කර ෙැනීමට අපට උපකාර කළ හැකි ක්‍රම දදස බලන්න) •This is called giving them ‘active support’ •All staff assisting the client should be aware of the plan
  • 52. 4. Implementation •In this phase care giver put the care plan into action (ස්ත්කාර ස්ැලැස්තම ක්රියාත්මක කරන්න) •Document the nursing interventions what implemented
  • 53. 5. Evaluation •This is the phase when we should re look at the plans and see if they are having the desired effects •නැවත සැලසුම් දදස බලා ඒවා අදප්ක්ිත ප්‍රතිඵල ලබා ෙන්දන් දැයි බලන්න
  • 54. 5. Evaluation … •Eg problem is lack of mobility •Plan- refer to the client for walking aid •Implementation- do it •Evaluation- client could mobilized with minimal support, no adverse effects
  • 56. Care plan fundamentals •Three core questions the care plan should answer: •what •why •how •
  • 57. Care plan fundamentals… •A nursing care plan should include: •The What: What does the patient suffer from? What do they risk suffering from? •The Why: Why does your patient suffer from this? Why do they risk suffering from this? •The How: How can you make this better?
  • 58. Types of care plan •Daily care plan •Weekly care plan •Monthly care plan
  • 59. Daily care plan • daily care plan is a written or visual description of each day. • Its goal is to help ensure a person who need others help and his or her caregiver has all their needs met from day to day while staying as active and engaged as possible (සියලු අවශයතා සපුරාලීම සහතික කිරීමට උපකාර කිරීමයි.)
  • 60. How do I create a daily plan •Can use a paper template or an activity board. • It can be written out in the style of a timetable, •It can be created on an activity board using visual prompts, pictures and cards for each activity.(ක්‍රියාකාරකම් පුවරුවක නිර්මාණය කළ හැක)
  • 61. Why use daily care plan •Certain daily events will always happen at a certain time •It anchors each day(එය සෑම දිනකම දමයි) •Regular bedtime, get up at around the same time each day and eat regular meals prepare for next day
  • 62. Why use daily care plan… •It keeps everyone informed(එය සෑම දකදනකුම දැනුවත් කරයි) •Other carers, family or friends can also see what’s happened earlier in the day and avoid repeating the same activity or meal
  • 63. A typical daily care plan •Morning – •Wake up, help with washing and dressing if necessary •Prepare and eat a heathy breakfast •Morning activity – gardening, cooking, a craft project •Coffee and newspapers •Quiet time to relax or take a nap
  • 64. A typical daily care plan… •Afternoon – •Prepare lunch and eat •Reminiscence(සිහිපත් කිරීම) – look at photos together, listen to favorite music or do some life story work •Activity – household chores(දෙදර දදාදර් වැඩ) •Take a break •Prepare evening meal
  • 65. A typical daily care plan… •Evening – •Watch TV, play a card game, run a bath
  • 66. Example- daily care plan for patient with dementia • Morning • Get up and perform a morning hygiene routine (brushing, toileting, washing face). • Make breakfast (have the person with dementia help as much as he/she is able and wants to do so) and clean up breakfast together. • Participate in an enjoyable art or craft project. • Take a break and have some quiet time (this is a good time for caregivers to do some meditation or reflecting). • Take a walk or engage in another planned activity.
  • 67. • Afternoon • Eat lunch and clean up the meal together. • Listen to some favorite old music or watch a favorite movie together. • Look at family photos and talk about memories of the images. • Try some physical activity, such as planting or weeding the garden. • Visit with a family member, friend or neighbor.
  • 68. • Evening • Eat dinner and clean up together. • Give a massage, start to wind down for bedtime. • Help with nightly hygiene routines, such as a bath or shower, oral hygiene and pajamas. • Play a crossword puzzle or game. • Read a favorite book passage and/or play some relaxing music before turning in for the night.
  • 70. Weekly plan •Weekly plans are designs to achieve the psychological, social and spiritual care addition to the physical needs •Aesthetic activities •Shopping •Eco visit
  • 71. Some recreational activities •Reading books, magazine and news papers • Listening to the music •Watching moves and television • Painting and drawing • Indoor and outdoor games •Occupational therapy (knitting, crafting,
  • 74. Monthly plan •This is covering the higher order needs of a client •Participating picnic •Attending cultural events •Gathering/companionship with friends, relatives
  • 78. Case scenario 1 for care plan • 82 years old Mr Simon is a retired employee, a widower in nursing home for receiving care. His son and daughter are far to the nursing home, visit the daddy once a month. His hearing and ability of vision is very low. He does not take usual diet because of loss of taste. The toileting habit of the Simon is not in routine, therefore he complain some distension of abdomen. And also, he is unable to pass urine therefore urine output is low. He has diagnosis of prostate enlargement but not in treatment. Urine color is dark. He is on medicines for high blood pressure. The mild ankle edema can be seen in both legs. Due to the distension and leg cramping he complain about difficult in falling sleep. He is worried about separated from the family. He always complain the monotonous and loneliness of his life.
  • 79. •Scenario 2 • 69 years old Margret is retired lady is in your work home her husband has passed away 6 years ago. She has suffering from diabetic mellitus 8 years and not on regular treatments due to non compliance, also she is having hypertension but not taken medical advice yet. She has a wound in her left leg. Therefore, she cannot walk alone. She is wearing spectacles for her reading and also far vision. This lady is also on oral Antibiotics. • Today she has not yet had her morning care and she looks worried. When you call her, she gets angry and don’t like to do anything. The days coming for Christmas in near future.