Home Health Nursing Care Plans
The care plan
- Increases consistency of care
- Focuses all interdisciplinary team members on the same problems
- Describes the patient’s functional abilities and needs
- Sets goals to maintain the patient’s highest level of functioning
- Addresses the patient’s physical, mental, emotional, and social needs
- Provides a reference to measure progress
The plan of care must address the following
- All pertinent diagnoses
- the beneficiary’s mental state
- The types of services required
- Supplies and equipment required
- Frequency of visits
- Rehabilitation potential
- Functional limitations
- Activities permitted
- Nutritional requirements
- Safety measures to protect against injury
- Discharge plans
- Any additional items which the HHA or physician want to include
The HHA staff’s other professional personnel shall have a substantial role in assessing patient needs, consulting with the physician to develop the overall plan of care. The patient has the too-right and should be encouraged, to participate in the developing of the plan of care before care is started and when changes in the established plan of care are implemented.
- How does an HHA evaluate whether the plan of care
- helps the patient attain and maintain his or her highest practicable functional capacity based on medical, nursing? and rehabilitative needs?
- including those provided under arrangement or contract, to ensure compliance with the specificity of community ordered in the plan of care?
Possible reference sources for standards of practice include
Standards published by professional organizations such as the American Dietetic Association, American Medical Association, American Medical Director’s Association, American Nurses Association. National Association of Activity Professionals, National Association of Social Work, etc. Clinical practice guidelines published by the Agency of Health Care Policy and Research
Current professional journal articles.
Care Plan Components
The American Nursing Association’s Standards of Clinical Practice outline the Nursing Process. This framework of critical analysis and planning is used universally by nurses in all areas of health care. Its six basic pans form the actual structure of the care-planning process:
- Assessment – data collection from the chart, physical nursing assessment. observation. interview with the patient. family. and caregivers. review of the OASIS data 30
- Diagnosis — stating the individual problems as nursing diagnoses
- Outcome Identification / Planning— formulation of the desired goal for resolution of the problem. setting priorities, identifying nursing interventions
- Implementation — putting the can plan into action
- Evaluation — analyzing, assessing the success and appropriateness of the can plan
The problem statement sums up assessment information into a specified functional category. No federal regulation specifies the exact wording or structure of the problem statement, but generally. problems are written in functional or behavioral terms. Problem statements are traditionally based on nursing diagnosis. Medical diagnoses can be a pan of the problem statement, but not the actual problem itself.
A sound practice for care-planning is to follow a check-list of problem identification:
- Review OASIS sections and entries
- And Review the patient’s entire chart
- Review the patient’s list of medical diagnoses and all medications
- Focus on the patient’s particular and individual strengths, needs, and preferences
- Review the Quality Measures
The most commonly used nursing diagnoses are ones sanction by NANDA. the North American Nursing Diagnosis Association, and arc grouped by functional health patterns. Elements often included are:
- whether the problem is actual or potential 10 what the problem is related to. such as medical diagnosis
- objective signs and symptoms of the problem, such as physical assessments and nursing observations
As evidenced by Shortness of breath Patient verbalizes fatigue when walking more than 10 feet
The problem should be dated and initialed when entered. changed. or deleted.
Goals The care plan goal can he to prevent a potential problem from occurring, to maintain a present status or level of functional ability or to solve a current problem. Elements In the focus on in writing the goal are that it is:
- Appropriate – for the patient’s needs. strengths, abilities. and cultural background
- Realistic – reasonably attainable
- Measurable — able to be objectively observed and evaluated
- Patient-centered – stated in terms of the patient’s actions
- Time framed — gives a target date or time estimate for the attainment of the goal
- Individualized — to the patient’s unique deficits, traits, and preferences
- Specific – each problem has a goal-specific to it, although each problem may have erased than one goal. example: Patient will verbalize understanding of the need to comply with diabetic diet Patient will lose one pound per week over the next thirty days
Goals are usually stated in terms of an action the patient will perform, such as the Patient will wash face and hands during the morning are every day. Entries in the goal column of the care plan should be initialed and dated when entered. changed. or deleted.
Interventions describe specific actions taken by the patient/caregiver to achieve the stated goal. and are based on standards of clinical practice. Like goals. interventions need to be specific. measurable. appropriate. and realistic. Interventions are worded in terms of what the caregiver will do to assist the patient to meet the stated goals for the problem. such as:
Offer patients four ounces of fluid eight times per day. Interventions should be initialed and dated when entered. changed. or deleted. Evaluation Evaluation of the care plan is an ongoing activity that examines the problem itself. Reasons for changing the care plan may be:
- The problem is resolved
- Goals were met
- Goals need to be bigger or smaller
- A new diagnosis or change in the patient’s condition is impacting the problem
- New medications or treatments need to be included
Individualizing the Care Plan When working to write a care plan individualized to the patient. considering the following areas and examples may help:
- Strengths – involved in activities, physically active, enjoys talking with friends.
- Preferences – doesn’t eat meat. dislikes showers Routines – likes to sleep late, used to taking shower in the afternoon.
- Noncompliance – refuses hearing aid or dentures, refuses medications, does not follow safety advice Cultural – lived on fain. Hispanic.
- Social – likes to keep to herself.
- Special needs – talking books.
- History – lived alone for ten years. worked as a secretary 0 Family Involvement family visits often, the husband died recently
- Spiritual beliefs – religion, the importance of religious practices and beliefs.