Care plans

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Introduction

Written nursing care plans ensure that the nurse responsible for patient care at any time during the animal's stay in the practice is confident to manage and treat the patient, to talk to the owners and give accurate updates on their animal's care, and to feel that the best possible care has been given to the animal at all times. Care plans require skill to write and this is something that improves with practise.

Basic Principles

The principles that are the foundation of care planning are:

  • 'Transparency'; this principle guides staff to an accurate assessment of what care is required for each animal, why that treatment is indicated and what care has already been given.
  • 'Best Possible Care'; a nursing care plan is specific to an individual patient which implies that each individual is assessed to receive the best possible care for that animal's condition, temperament and response to treatment.
  • 'Record Keeping'; a written nursing care plan creates a record of what was done, by whom and why. Unfortunately this aspect is becoming more pertinent in our increasingly litigious society, and the registration of nurses has altered the responsibility for care given away from the veterinary surgeon.

How to Write a Care Plan

Nursing care plans are derived from human medicine and should include the following elements:

Assess

A full assessment of the patient is usually carried out when admitting them to the practice. It includes a full history, reason for admission, and the veterinary procedures that are expected to be carried out at that time. In addition, information on the animal's normal routines, known allergies, temperament and reproductive status should be noted.

Once admitted, this process continues by the addition of baseline physiological parameters such as weight, blood results, heart rate, respiratory rate, hydration status and other parameters indicated by the animal's presenting complaint.

This information should allow you to begin to assess any special adaptations that may be necessary to allow the patient to be more comfortable given their disease or the surgical process that they are about to undergo, The assessment should extend beyond the search to reach a medical diagnosis and instigate treatment for the condition diagnosed; factors such as the patient's environment can be included in the assessment of a patient's needs, and an attempt at prioritising the care required begins at this stage.

Plan

Planning care essentially means agreeing goals that can be sensibly achieved during the patient’s stay by carrying out the necessary care required to achieve these goals. These goals must be realistic and personal to the patient: many practices have set protocols for specific surgical procedures, for example - these must be adapted for each patient to reflect the needs of the individual concerned. The care given should reflect the current knowledge of care giving for each specific condition or surgery.

Implement

Implementing a care plan is more complex than caring for the patient during their stay - it includes the documentation of everything that is done for the patient, noting the consent given by the owner for the care required, and communicating the care given to the vet, to colleagues and to the owner. When giving care to the patient, the previous process of assessment and planning needs to be considered carefully so that the care is given in a way that is tailored to suit the individual animal as much as possible.

Evaluate

Evaluating the care plan requires an objective measurement indicating whether the goals set have been achieved - the evaluation also needs to include a broader consideration of whether the goals are still realistically achievable. As patient care is a dynamic process, the goals may require re-evaluation, and this can be done by returning to the beginning of the care planning process, and re-assessing the animal's care needs and the goals achievable during their stay. The use of baseline parameters on admission facilitate the process of evaluation and can prevent misinterpretation of the response to the care given and the successful achievement of the goals set. Where changes are made to the care plan at this stage be sure to record the reason for the change as this can be difficult to follow retrospectively if the records are considered for any reason at a later date.