CARE PLANSCARE PLANS

What are “care plans?”What are “care plans?”

By C SpainBy C Spain

Care plans are:Care plans are:

Care plans are made up of four Care plans are made up of four different parts or stages.different parts or stages.

They are ---They are --- AssessmentAssessment PlanningPlanning ImplementationImplementation EvaluationEvaluation Remember ….A.P.I.E.Remember ….A.P.I.E.

Assessment.Assessment.

This is the part of the process where This is the part of the process where the individual client’s needs are the individual client’s needs are assessed assessed

From this assessment we can get a From this assessment we can get a fuller picture of their individual needsfuller picture of their individual needs

The assessment should involve all The assessment should involve all people who have had input into the people who have had input into the clients care, this would include—clients care, this would include—

Assessment.Assessment. Nurses Nurses RelativesRelatives Medical staffMedical staff Social servicesSocial services Speech and languageSpeech and language To name just a fewTo name just a few This type of assessment is referred to as a This type of assessment is referred to as a

“multi-disciplinary assessment”“multi-disciplinary assessment” By using all the information that we can By using all the information that we can

we should be able to understand our client we should be able to understand our client better and in a more better and in a more “holistic“holistic” way.” way.

AssessmentAssessment

It is during this stage that we can It is during this stage that we can identify where the client has difficulty identify where the client has difficulty and where their problem areas are.and where their problem areas are.

So it not only helps us to identify So it not only helps us to identify their individual problems and needs, their individual problems and needs,

But it also gives us a full picture of But it also gives us a full picture of them helping us to understand their them helping us to understand their life, desires and expectations.life, desires and expectations.

AssessmentAssessment

Most importantly you should talk to Most importantly you should talk to the client helping to understand their the client helping to understand their particular individual problems and particular individual problems and needs. Trying to.. “look at the world needs. Trying to.. “look at the world through their eyes.”through their eyes.”

This phase should also start the This phase should also start the client carer relationship, which client carer relationship, which should be based on trust, should be based on trust, understanding and empathy.understanding and empathy.

Planning.Planning.

The next stage of this process is the The next stage of this process is the planning stage.planning stage.

It is during this stage that we can try It is during this stage that we can try to understand the client’s problem to understand the client’s problem and with them look at a way of and with them look at a way of reducing it.reducing it.

The plan must involve all those people The plan must involve all those people who will be using it who will be using it

It must involve the client.It must involve the client.

PlanningPlanning

It is always best to look at ways in which It is always best to look at ways in which we can assist the client to manage we can assist the client to manage themselves as best as they are able to.themselves as best as they are able to.

This is called giving them “active This is called giving them “active support”support”

And all staff assisting the client should And all staff assisting the client should be aware of the plan.be aware of the plan.

But don’t forget that all plans should be:But don’t forget that all plans should be:

AssessmentAssessment

It must be It must be attainableattainable It must be It must be safe safe It must have It must have an end goalan end goal It must be It must be measurablemeasurable And they must be And they must be realistic.realistic.

Implementation.Implementation. This quite simply means putting the plan into This quite simply means putting the plan into

progress.progress.

All that you have discovered about a clients All that you have discovered about a clients particular problemparticular problem

can now help you to reduce it or relieve it can now help you to reduce it or relieve it completely.completely.

Using all the resources that you need for example, Using all the resources that you need for example,

Outside help, Using any aids required, for example Outside help, Using any aids required, for example special knives and forks, Plate guards or hoists.special knives and forks, Plate guards or hoists.

Implementation.Implementation.

BUT NO MATTER HOW GOOD A PLAN BUT NO MATTER HOW GOOD A PLAN IS, WITH ARE DEALING WITH IS, WITH ARE DEALING WITH UNPREDICTABLE PEOPLE, AND THEIR UNPREDICTABLE PEOPLE, AND THEIR NEEDS WILL CHANGE.NEEDS WILL CHANGE.

So the next phase is very important.So the next phase is very important.

EvaluationEvaluation

This is the phase when we should re-This is the phase when we should re-look at the plans and see if they are look at the plans and see if they are having the desired effect for example:having the desired effect for example:

Problem-- is mobilityProblem-- is mobility Plan is-- refer to client for walking aid.Plan is-- refer to client for walking aid. Implementation—Zimmer frame Implementation—Zimmer frame

received, /No replyreceived, /No reply

Evaluation.Evaluation.

Evaluation. May mean re-try as Evaluation. May mean re-try as possibly in above scenario or to possibly in above scenario or to move on to the next plan for that move on to the next plan for that problem (“problem (“ChainingChaining”)”)

For Example---Teaching the client For Example---Teaching the client how to use a Zimmer frame, at first how to use a Zimmer frame, at first with assistance.with assistance.

What do we assess?What do we assess?

We assess looking back to our We assess looking back to our activities of daily living, and more activities of daily living, and more that is:that is:

(Group to look again at the ADLs)(Group to look again at the ADLs)

What are they?What are they?

What do we assess?What do we assess?

CommunicationCommunication Personal hygienePersonal hygiene DressingDressing SleepingSleeping MotivationMotivation MobilityMobility EliminationElimination

What do we assess? What do we assess?

RiskRisk Eating and drinkingEating and drinking BreathingBreathing MemoryMemory OrientationOrientation BehaviourBehaviour

What do we assess? What do we assess?

Loss and changeLoss and change SexualitySexuality Social relationshipsSocial relationships Personal and spiritual fulfilmentPersonal and spiritual fulfilment CognitionCognition And moreAnd more

Overview.Overview.

When a new client come in, they should be When a new client come in, they should be Assessed for any problems relating to the Assessed for any problems relating to the above.above.

If they have problems in these areas then a If they have problems in these areas then a care plan should be drawn up to guide them care plan should be drawn up to guide them to a goal in order to either:to a goal in order to either:

Resolve the problem Resolve the problem OrOr To find a way of managing with it, without To find a way of managing with it, without

the problem interfering with their daily lives.the problem interfering with their daily lives.

Example one.Example one.

Example two.Example two.

Thank youThank you

Mr C Spain.Mr C Spain.