NSG 4055 Project Creating a Plan of Care
NSG 4055 Project Creating a Plan of Care
Utilizing the information you have gathered over the weeks
regarding the specific illness group you identified, this week, you will create
a plan of care for your chronic illness group.
Create the plan in a 4- to 6-page Microsoft Word document
(the 4–6 pages include the holistic care plan). Include the following in your
Start the paper with a brief introduction describing the
chronically ill group you selected and provide rationale for selecting this
illness and the participants. Clearly identify the Healthy People 2020 topic
chosen and why this topic was chosen.
You will want to compile the information gathered from Weeks
1–4 over 2 to 3 pages. This should be in APA format and paragraph form. This is
not to be copied and pasted from previous assignments. It is to be a summary of
The paper should include the care plan for your chronic
illness group organized under the following headings:
Assessment Data (objective and subjective)
Actions and Interventions
Evaluation of Patient Outcomes
You will need to ensure that the care plan is holistic and
includes at least 3 nursing diagnoses related to the topic and interview
results from the previous weeks.
Include strategies for the family or caregiver in the care
plan and provide your rationale on how they will work.
Include a reference page to provide reference for all
citations for the paper as well as the care plan.
On a separate references page, cite all sources using APA
Use this APA Citation Helper as a convenient reference for
properly citing resources.
This handout will provide you the details of formatting your
essay using APA style.
You may create your essay in this APA-formatted template.
Caregiving can slowly become a reality as a loved one ages, or it can be a sudden change resulting from an accident, a new diagnosis or a hospitalization. Regardless of your individual situation, it is crucial to understand that the nature of providing care for someone can change in an instant. For this reason, it is especially important to approach caregiving in an organized fashion. Should anything change, you will have a plan of action to build off and a list of available resources ready to help you meet new and emerging needs.
An elder care plan can be an organizational tool, an informal or verbal agreement with a loved one, or a formal contract used to coordinate payment for care services. Plans can vary from daily to-do lists to detailed weekly accounts of amounts and types of care provided. The following steps can help you create your very first care plan or reevaluate your current approach to caregiving.
Assess the Current Caregiving Situation
The first step in creating an elder care plan is to gather information and address any problem(s) at hand. To create a well-rounded strategy for dealing with concerns, all areas of a senior’s daily life must be taken into account.
Review a loved one’s home environment, activities of daily living (ADLs), health status, medical and legal documents, and financial situation to ensure nothing is overlooked.
Print a copy of this ADL Assessment Checklist for Elderly Living Alone
Some seniors may be resistant to such an “intrusion” into their personal affairs, but getting a complete snapshot of their current situation is vital for developing an appropriate plan of care. On the other hand, this first step is also useful for identifying the areas in which a loved one is still self-sufficient and able to retain their independence.
Identify Care Needs and Set Goals of Care
The next step revolves around two central questions:
- What is lacking or being overlooked in your loved one’s current routine?
- What objectives would you like to help them achieve?
Based on the results of the care assessment you completed, make an ordered list of all shortcomings or concerns, placing the highest priorities at the top. Your loved one’s immediate health and quality of life are of utmost importance, so if they are losing weight or not complying with their medication regimen, these problems must be dealt with first.
Even if you do not identify any flaws in their day-to-day schedule, setting goals for their wellbeing is a useful way to convey your interest in helping them thrive. For example, “I want Mom to be safer in her own home,” “I want Dad to eat better,” and “I want my husband to have a higher quality of life” are all excellent caregiving goals that can be achieved in numerous ways. Don’t forget to include your loved one’s own desires for the future when creating these objectives as well.
Longer-term objectives like financial planning, advance care planning, estate planning and funeral planning can be addressed with the same two questions. These preparations are extremely important and can be time sensitive, depending on your loved one’s current situation. While these matters may be less pressing than rectifying health issues, the sooner they are addressed, the better. Proactive planning in these areas increases the likelihood that a loved one will be able to afford the lifestyle they have in mind for the future, guarantees that their health care and end-of-life wishes are respected even if they can’t convey them, and clearly specifies how their estate will be administered. Your loved one’s participation in setting these goals is paramount, so long as they are still competent to make these decisions.
Create a Comprehensive Care Team
A caregiver shouldn’t have to coordinate and execute all these tasks unaided. Embarking on this journey alone can be overwhelming and frequently leads to serious physical and emotional consequences of caregiver burnout. The purpose of creating a care team is to take inventory of all resources at your disposal and encourage communication and cooperation amongst all those who are willing to participate in your loved one’s care plan. Friends, family, neighbors, volunteers and other members of their community are the most obvious candidates for assisting with a loved one’s day-to-day needs and personal care. It is best to assemble a team of constructive individuals who are able to lend a hand or an ear when you need it most.
Of course, the more complex medical, legal and financial aspects of a care plan are best handled by experienced elder care experts. Specialists, such as elder law attorneys, therapists, benefits counselors, certified public accountants (CPAs), financial advisors, geriatricians and social workers, can be valuable additions to an elder’s care team. If your caregiving situation is particularly complex, a reputable geriatric care manager (also known as an Aging Life Care Professional) can assist in organizing, monitoring and facilitating your loved one’s care as well.
Match Care Team Members with Solutions
In some cases, a team member’s specific tasks will be obvious. An elder law attorney will handle drafting POA and advance directive documents, whereas a financial advisor can assist with money management strategies, investments and insurance products. Delegating caregiving tasks to friends and family members on your care team can be a little more challenging.
Make a list of viable solutions for each gap in your care plan. For example, your goal is helping Dad eat healthier meals more frequently. To achieve this goal, your brother and sister who live nearby could take turns delivering homemade meals or inviting Dad over for dinner a few times each week, and long-distance siblings could contribute funds for a subscription food delivery service to make up the difference. Try to identify each person’s individual strengths or abilities and match them with feasible solutions. These individual assets can include proximity to the care recipient, free time in their schedule, monetary contributions, and skills like cooking, cleaning, nursing experience, and communicating. Get creative with how you appraise each team member and generate ideas for how they might be able to contribute.
Investigate Other Senior Resources
Any gaps or holes that remain in your care plan after you assign responsibilities to your team members should be filled by professional services, and/or federal, state, or local programs. Your local Area Agency on Aging (AAA) can assist you in finding appropriate resources for your caregiving situation. While most families would prefer to limit their care team to family and close friends, this is not always realistic. Professional in-home care, adult day care, and respite services are often necessary to fill in any remaining holes. It can take a great deal of research to find the right programs or services to complete your care plan, but this effort is well worth it.
Put Your Care Plan Into Action
The purpose of having a care plan and care team in place is to promote communication and unified efforts for the welfare of both the care recipient and the caregiver. A divide and conquer approach to caregiving is far more sustainable than a sole caregiver taking on all these responsibilities. Keep in mind that a care plan is an ever-evolving tool. Professional care providers use similar organizational techniques and regularly evaluate and update each client’s plan of care to ensure all their needs are being met. Finding the best solutions may take some trial and error, and your loved one’s needs are likely to increase over the long term, so flexibility is key.
Even if your loved one does not currently need a care plan, beginning to put these pieces of the puzzle into place can save valuable time and help you avoid a great deal of stress later on. They don’t necessarily need to share their detailed financial statements or medical records with you just yet, but asking them to put together an updated file containing this information can be incredibly helpful in the event of an emergency. This goes for medications, health information and legal documents as well. Should something happen, you will know where to access the materials you need to make care decisions quickly and confidently.