Developing a Plan of Care



Developing a Plan of Care

            After completing a health assessment, you have a baseline for your family member and a starting place for developing a plan of care. A comparison with the baseline can show an improvement or decline in their state of health. Initially, compare their baseline to the normal for their age, race, and gender. Then, if you have access to their prior medical history, compare their current baseline to their medical history. Finally, look at what is typical for them. It will tell you whether a low or high reading for their lab work should cause you concern or not.

            Suppose someone normally has a high potassium level and gets a high potassium reading back today as a lab value. In that case, I consider that an expected reading for them since it’s one the doctor would already know is an issue. However, if they usually have a normal reading but it’s below normal today, I would be concerned and call the doctor to ask what treatment we needed to start. Why? Because low potassium can cause the heart to beat irregularly.

Develop a Problem List

     Develop a problem list based on your information while doing your baseline health assessment. First, include everything you found that was causing suffering in any way needed medication, any treatment, or had the potential to cause harm. Then, prioritize them based on how they affect the quality of life or their potential to cause harm if you ignore them.

Make two lists.
  • Those that don’t need daily attention are placed in a folder to re-evaluate quarterly or more frequently if symptoms develop.
  • Those who currently need daily or weekly attention become the foundation for your care plan.

     The conditions on your problem lists (both lists) are the ones you need to learn how to identify what is normal, warning signs of a problem, normal lab values, risk factors to avoid, how to treat problems as they develop to keep them out of the hospital, and anything else you can learn to keep them as healthy as possible to reduce your workload. Why? Because the healthier they are, the better it is for both of your lives.

Establish Goals

     Caregiving may be a short- or long-term commitment. Either way, determine your recovery goals. Then after setting your goal, evaluate your progress to determine if you are achieving them.  

Here are examples of goals.

  • Long-term goals: Coordinating services and treatments so they return to doing everything they could do before their accident.
  • Short-term goal:  Today, he will get out of bed and sit in a chair for 3 hours. This week the patient will learn to button her shirt.
  • Keep your goals focused on progressing toward recovery.
  • Please encourage your family member to do as much on their own as possible.
  • If PT or OT comes to your house to work with your family, try to get everyone working on the same goals. Example OT and PT both may work on independent eating at the table. While OT works on hand-to-mouth strengthening, PT works on core muscle strengthening for sitting up.
  • Establish your goals on the first of the week and celebrate your victories at the end of the week. Keep the goals small and measurable. The easier to achieve, the better they become to provide positive reinforcement and encouragement.
Create Action Steps

     Coming up with action steps can be difficult for someone with no experience. You may wonder where to get ideas. Start by looking through some of the topics found on this website. Then look through some of the organizations found on the Resources pages. There are lots to consider, and most offer guidance documents, toolkits, or other materials for you to consider. Look at several and decide what works best for you.

     Keep your plan simple. Don’t make it elaborate or complicated. Keep in mind; that you don’t want to spend time doing busy work. Only add to the plan what is productive and helpful to your family member’s recovery. When one task can address multiple problems, let that one solution solve 15 problems if it can. You don’t have to have a separate action for each problem.

     There are no rules for how you put your plan together–make it work for you. One approach is to make a calendar of tasks done on certain days of the week. Another way is to plan your activities around similar tasks, such as performing skin or wound care activities at bath time. Use whatever process seems easiest or most natural to you as a workflow. Do what feels natural and what works easiest.

Implement Your Action Plan

     Don’t be surprised if some things don’t work as you implement your action plan. Expect that you’ll need to tweak the plan a lot. Until you get a sense of what works, plan on making daily changes. Keep at it until it feels like you have it where you and your patient feel comfortable. At that point, you will be in “maintenance” mode rather than design mode. Savor the feeling because something will happen to make you need to change it before too long—it always does. Learn to be flexible.

How is Your Plan Working?

     It’s a good idea to periodically check your plan to see if you’ve overlooked anything. You also need to confirm that you’re making progress. You do that by comparing where you are now with your baseline measurements.

     You need to track your progress to determine if you are achieving your goals. With each treatment that can support a measurement, do one and record it. For example:

  • Wounds:  Record measure the widest point left to right and up and down. Then, using a q-tip, measure how deep it is. Describe the color, smell, thickness, or odor of any drainage.
  • Insulin:  Record the Blood sugar readings for the day and the amount of insulin given based on that reading.
  • Vital signs:  Record blood pressure, pulse, respiration, and oxygen saturation for the time of day. Note any unusual events associated with the reading, such as pain.

     When you see grouped data, you can analyze information to see if trends (similar behaviors) emerge over time. After looking over the information, if you see an improvement, you can call the doctor to discuss changing the treatment plan or if a doctor’s order is not needed, make the change yourself. If you achieved your goal, take that step away and pat yourself on the back.

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