Nursing care plans are blueprints for residents’ entire care needs, and direct the actions of all health care team members. Written nursing care plans are usually arranged into the three parts of Care Plan Problem, Care Plan Goal, and Care Plan Interventions.
Problem statements are traditionally based on a nursing diagnosis. The nursing diagnosis is a problem that nurses can identify and treat. Medical diagnoses can be part of the nursing care plan problem statement, but not the actual problem itself. The most commonly used nursing diagnoses are the ones approved by NANDA, the North American Nursing Diagnosis Association, and are grouped by functional health patterns.
The goal can be to prevent a potential problem from occurring, to maintain a present status or level of functional ability, or to resolve a currently existing problem. Goals are usually stated in terms of an action the resident will perform.
Interventions describe specific actions taken by the staff to achieve the stated goal, and are based on standards of clinical practice. Like the goals of nursing care plans , interventions need to be specific, measurable, appropriate, and realistic. Interventions are worded in terms of what the staff will do to assist the resident to meet the stated goals for the problem.
Evaluation is an ongoing activity that examines the problem itself, the goals, and the interventions to determine if they are still applicable or if changes to the care plan need to be made.
See how these principles are applied by viewing these sample care plans:
The latest RAI Manual changes have been published by CMS. Updated sections include changes that affect G0110 and G0120 ADL Self-Performance and Support, H0200 Toileting Program, K0710 Percent Intake by Artificial Route, and section O Therapy Services.
There are a number of changes to coding instructions that affect assessments for Significant Change in Status, OMRA, Discharge, and Significant Correction.
There are some changes to instructions for coding CAA completion dates.
All LTCS Books publications will be updated in January 2014 to reflect these changes.
Full Text MDS RAI Manual October 2013 Changes
Summary of MDS RAI User Manual Changes
Minimum Required MDS Assessments Chart
OBRA Assessment Scheduling Chart
The nursing care plan goal can be to prevent a potential problem from occurring, to maintain a present status or level of functional ability, or to resolve a currently existing problem. Goals are usually stated in terms of an action the resident will perform. Elements to focus on in writing the goal are that it is:
Appropriate – for the resident’s needs, strengths, abilities, and cultural background
Realistic – reasonably attainable
Measurable – able to be objectively observed and evaluated
Resident centered – stated in terms of the resident’s actions
Time framed – gives a target date or time estimate for attainment of the goal
Individualized – to the resident’s unique deficits, traits, and preferences
Specific – each problem has a goal specific to it, although each problem may have more than one goal
Resident will wash face and hands during morning care every day.
Resident will verbalize understanding of the need to comply with diabetic diet.
Resident will lose one pound per week over the next thirty days.
Read more about how to write nursing care plans in the book Complete Nursing Care Plans for Long Term Care - 143 nursing care plans in the book and on the CD can be made resident specific and converted to I-care plans in one click.
Nearly two million home health care workers will benefit from the Minimum Wage and Overtime Protections extended to direct care workers by the U.S. Department of Labor, according to an announcement by the department’s Wage and Hour Division September 17, 2013.
Scheduled to become effective Jan. 1, 2015, the legislation will affect workers who provide essential home care assistance to elderly people and people with illnesses, injuries or disabilities: home health aides, personal care aides and certified nursing assistants.
The Department of Labor has created a new web portal with interactive web tools, fact sheets and other materials to help families, other employers and workers understand the new requirements. These, along with information about upcoming webinars on the rule, are available at:
Minimum Wage and Overtime Pay for Direct Care Workers