1. Terms and Definitions
• Care plan – an individual plan of action for each resident
• Nursing process – a problem-solving technique that consists of eight steps:
Data collection – the act of collecting as much information as possible about the resident
Assessment – an appraisal of the whole person to establish a baseline and determine the resident’s potential and need for help
Problem – needs that a resident cannot meet alone
Need – something essential or desirable that a person is lacking or feels is lacking
Goal – the desired result, what one hopes to accomplish
Approach – a way or ways to reach the goal
Implementation – carrying out a plan of action
Outcome or evaluation

2. Description of a Care Plan
• The care plan is an individual plan of action for assisting the resident to fulfill basic human needs, special personal needs, and to successfully conduct the activities of daily living. The care plan helps the resident live at his/her fullest potential.
• The care plan is prepared for each resident.
• The care plan is a form of written communication.
• Legally there must be a written care plan for each resident in a certified bed. For a licensed-only facility, there is no specific requirement for a written care plan, but the resident’s needs must be met.
• It provides a means for planning, assessing, implementing, and evaluating an individual resident’s care.

3. Development of a Care Plan
• During a care conference, the care plan is developed with input from members of the nursing and medical staff (interdisciplinary approach), especially the nurse assistant, and other consultants (e.g., activity director, social worker, physical therapist, occupational therapist, dietitian) as needed.
• The resident and family are invited and urged to participate.
• The resident’s needs and strengths (capabilities) are discussed.
• Team members suggest how to meet these needs and build on the resident’s strengths. The nurse assistant’s input is extremely important at this stage because he/she is often the most familiar with the resident.
• From these suggestions, the charge nurse lists the long- and short-term goals for the resident and how they are to be met.

4. Development of a Care Plan
• The long- and short-term goals and how they are to be met are then transferred to a nursing care form. The nurse assistant should become familiar with the goals to provide appropriate care.
• The plan is always discussed with the resident and is part of his/her record.

5. Goals of a Care Plan • To empower the resident
• To assist the resident in fulfilling his/her basic human needs of:
Maintaining adequate nutrition
Eliminating waste
Being active (mobile)
Getting sufficient rest
Communicating with others
Breathing efficiently
Carrying out proper hygiene
Satisfying spiritual needs
Receiving emotional support

6. Goals of a Care Plan
• To assist the resident in conducting the activities of daily living – Activities of daily living are activities that every person performs each day in caring for himself/herself. (See Figure 10.1.)

7. Figure 10.1 – Sample Care Plan

8. Factors That May Cause the Resident to be Unable to Meet Personal Needs
• Poorly fitting dentures, digestive disorders, lack of appetite
• Urinary catheters, constipation
• Respiratory disease
• Needing a walker or cane, confined to a wheelchair, foot problems such as bunions
• Speaking in a different language, memory loss, hearing or vision loss, stroke, confusion
• Unable to attend religious services
• Anxious, depressed
• Poor sleeping patterns, takes frequent short naps, frequently up to go to the bathroom
• Unable to reach his/her entire body to bathe

9. How the Care Plan Helps the Nurse Assistant
• Gives specific instructions regarding care to be given
• Provides information needed before giving care to the resident
• Provides guidelines for the health care team to ensure continuity of care
• Assists in organizing and planning work

10. Responsibilities of the Nurse Assistant in Relation to the Care Plan
• Contributes to, is familiar with, and uses the care plan for each assigned resident
• Knows of and implements any changes in the care plan
• Follows the care plan when giving care, including short- and long-term goals
• Observes and assesses the resident’s response to care given
• Reports the resident’s response to care given
• When assigned, documents the resident’s response

11. Conclusion
The care plan is very important to the nurse assistant when planning and administering care to assigned residents. Be sure you understand and follow the policies and procedures related to the care plan in the long-term care facility where you are employed.