Simplified Explanation and Tips
Planning involves creating a detailed care plan based on the person’s needs and the issues identified during the assessment. Here’s how to approach it effectively:
Top Tips:
- Identify Key Problems:
- Focus on the most important issues the person is experiencing, such as pain, anxiety, difficulty moving, or trouble breathing.
- If they have recently had surgery, think about common post-operative problems they might face, like pain, nausea, or risk of infection.
- Document Self-Care Abilities:
- Record what the person can do for themselves. For example, can they eat, dress, or move independently? This goes in the “self-care” section.
- Set Review Times:
- Decide how often to check on the problems you’ve identified. For example, if they’re in pain, you should review them much sooner than 24 hours later.
- Stay Focused:
- Only include information that directly relates to the issues you’ve identified. Avoid irrelevant details.
- Complete All Sections:
- Make sure all parts of the planning documentation are filled out properly. Don’t skip anything!
Common Mistakes to Avoid:
- Missing Self-Care Details: Forgetting to document what the person can manage on their own.
- Lack of Specific Nursing Actions: Not including detailed, evidence-based interventions to address the identified problems.
- Identifying Irrelevant Problems: Missing key issues and focusing on unrelated information, like equipment use, without addressing the care priorities.
- Omitting Review Times: Failing to specify when the problems will be reassessed.
- Documentation Errors: Not signing, dating, or printing your name on the care plan.
