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Patient care plans are based on nursing theories, and a number of well-known nursing models underlie the different types of care plan. A nursing model is a framework to enable planning and recording care; an example of which is the Orem model. Abraham Maslow's hierarchy of needs is an easy theory to understand and can be found at the heart of many nursing models. Maslow theorized that human beings have needs and that these needs can be prioritized, with for instance, the need for oxygen being at the most basic end of the scale. Different types of care plans based on different types of theory may be suitable for different care settings. A care plan in a psychiatric ward is likely to have some differences from a care plan in an acute medical ward.
Agree on the type of care plan to be used in your care setting. Familiarize yourself with the model of care that underlies this care plan. Assess the patient in a holistic way. This means you look at him as a whole person, his emotional, psychological and social needs as well as the physical needs. All these needs will form the basis of an assessment form, which will be completed on his admission. Involve him in this assessment, if possible. Know and understand as much about him as you can. Liaise with others in the multidisciplinary team in this assessment. If it is appropriate, talk to the patient's relatives or friends, while upholding the law and policies on confidentiality.
Set a number of goals for the patient. Make sure these goals are realistically achievable. The goals should be measurable. For instance, a goal may be that the patient can walk unaided to the end of the corridor in one week. Break this goal into small steps.
Decide when the care plan is to be reviewed. Make sure you have signed and dated the care plan, as these are accountable documents which are open to scrutiny in the event of a problem or litigation.
Review the care plan regularly. The review period may vary. The need to revisit the care plan of an elderly resident in a care home will not be the same as in an intensive-care unit, where it may need to be reviewed every few hours.
Set new goals on the care plan as and when the patient's condition alters. Make sure that changes are passed on to new staff verbally as well as in writing. All relevant staff should have access to the care plan. It should be a working active document, not something that is completed then filed away.
Use respectful language in your care planning and review.
Do not use liquid eraser. Cross out an error and initial it.
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