1. Maintaining a Care
Plan

2. Care Plan…
•Care plans (or support plans) are created for
individuals in care homes.
•A care and support plan will clearly lay out
(පැහැදිලිව ලෑස්තියි)
•The level of support a person needs,
•how the support will be given
•what the aims and goals of the care are
•any other necessary details.

3. What is a care plan
•A care plan is a form where you can summarize
a person’s health conditions, specific care
needs, and current treatments.
•The care plan should outline what needs to be
done to manage the care needs.(කළ යුතු දේ
දෙනහැර දක්වන්න)

4. What is a care plan…
• It can help organize and prioritize caregiving
activities. (රැකවරණය සංවිධානය කිරීම සහ ප්‍රමුඛත්වය
දීම)
•A care plan can give you a sense of control and
confidence (පාලනය සහ විශ්වාසය)when managing
caregiving tasks
•help assure you that the care recipient’s needs are
being met.(ස්ත්කාර ලබන්නාගේ අවශ්‍යතා ස්පුරාලන
බවට ස්හික වීමට උදවු කරන්න.)

5. What is a care plan…
•Having a care plan can help you as a caregiver,
especially if there are multiple caregivers, to aid
with transitions and.(ස්ංක්‍රාන්ි ස්ඳහා උපකාර
කිරීම),
•to have all important information in one
place.(සියලුම වැදගත් ගතාරතුරු එක තැනක තබා
ගන්න)

6. What is a care plan…
•A care plan documents the process of identifying a
patient’s needs(ක්ියාවලිය දේඛනෙත කරයි)
• facilitating holistic care, typically according to a
five-step framework.(පිපූර්ණ සත්කාර සඳහා පහසුකම්
සැලසීම කරයි)
• A care plan ensures collaboration of care givers
with other healthcare providers.(සහදයෝගීතාව
සහතික කරයි)

7. Date
&
Time
Assessment
Problem
/ Need
Planning Implementation Evaluation

8. Why we need to have a care plan
•To identify the client’s health care status
•To identify the client’s actual and potential
health problems
•To establish the care for identified
needs(හඳුනාෙත් අවශ්යතා සඳහා රැකවරණය
ස්ථාපිත කිරීම)

9. Why we need to have a care plan…
•To document the patient’s needs and wants, as
well as the interventions (or implementations)
planned to meet these needs.
• As part of the patient’s health record
• To use to establish continuity of care

10. What are the benefits of a care plan?
•Reduce emergency room visits and hospitalizations
•Improve overall medical management for people
with a chronic health condition, like Alzheimer’s
disease.
•Retain quality of life (ජීවන තත්ත්වය පවත්වා ගන්න)
•independence for the care recipient.

11. What are the benefits …
•Help care givers to focus on patients in a holistic,
big-picture
•To Provide individualized unique care
•Balance both your life and that of the person to
whom you are providing care(ඔගේ ජීවිතය ස්හ
ඔබ රැකවරණය ස්පයන පුද්ගලයාගේ ජීවිතය ගදකම
ස්මබර කරන්න)

12. What are the benefits …
•To better understand their care needs to family
members and loved ones , health conditions and
how they can offer additional support.
•Ensure that the care seeker consistently receives
the right level of care

13. What are the benefits …
•Any changes to the resident’s health condition will
be carefully noted in their health record.
•Allows a team of care givers, nurses as well as
physicians, assistants, and other care providers to
access the same information (එකම ගතාරතුරු ගවත
ප්රගේශ්‍ වීමට), share opinions,
•collaborate to provide the best possible care for the
patient.(රැකවරණය සැපයීමට සහදයෝෙදයන් කටයුතු
කරන්න)

14. What are the benefits …
• A care plan helps care team members organize aspects of
patient care according to a timeline.(කාලරාමුවකට අනුව
දරෝගී සත්කාරක අංශයන් සංවිධානය කරන්න)
• It’s also a tool for them to think critically(ඔවුන්ට
ගරෝගියාගේ ශ්‍ාරීරික, මගනෝවිදයාත්මක, ස්මාජීය ස්හ
අධ්‍යාත්ික රැකවරණය ස්ඳහා ස්හාය වන ආකාරගයන්
පරිපූර්ණ ගලස් විශ්‍තගේෂණාත්මකව සිතීමට ගමවලමක් ගලස් )
and holistically in a way that supports the patient’s
physical, psychological, social, and spiritual care.

15. What are the benefits …
•For patients, having clear goals to achieve will make
them more involved in their treatment and
recovery.(දරෝගීන් සඳහා, සාක්ෂාත් කර ෙැනීම සඳහා
පැහැදිලි ඉලක්ක තිබීම)
•Ensuring that you receive the same care regardless
of which care worker is on duty(කුමන දස්වකදයකු
රාජකාිදේ දයදී සිටියත් ඔබට එම දස්වය ලැදබන බව
සහතික කිරීම)
•Ensuring that the care you receive is recorded

16. What should be included in the care plan
•Personal Information (name, date of birth,
contact information)
•Health conditions, medical history
•Medicines, dosages, and when/how given
•history of injuries and illness

17. What should be included in the care plan
•Health care providers with contact information
•Health insurance information
•Emergency Contacts, family information
•Employment history
•Culture and religion to give carers and staff

18. What should be included …
•Goals and aspirations: What the care seeker wants
to get out of their care(ඉලක්ක සහ අභිලාෂයන්)
•The care seeker’s hobbies, likes, dislikes and
preferences on meals and daily routine
•Who is paying for the care: The care seeker’s
personal budget(පුද්ගලික අයවැය)
•Payment details

19. What should be included …
•Details of key dates and life events (this is
particularly important for care seekers with
dementia)
•Equipment, adaptations, or specific medical
care needed
•Details of continuity of care
•Details of end of life care, if required (this is
often offered in a palliative care home)

20. Components of the care plan
•Assessment
•Problem identification
•Planning for resolving the problem
•Implementation
•Evaluation

21. 1. Assessment
•The clients’ needs are assessed
(ගනුගදනුකරුවන්ගේ අවශ්‍තයතා තක්ගස්තරු කරනු
ලැගේ)
•care giver can get a fuller picture of their
individual needs

22. 1. Assessment…
•The assessment should involve all people who
have involve the client’s care.
•A needs assessment will look at clients’ unique
care requirements and the level of support
need, as well as the type of care home that
would best suit (ෙනුදදනුකරුවන්දේ අේවිතීය
සත්කාර අවශයතා දදස බලනු ඇත)

23. 1. Assessment…
•Most importantly you should talk to the client
helping to understand their particular individual
problems and needs
•Trying to ‘look at the world through their eyes’
•start the client –carer relationship which should
be based on trust, understanding and empathy

24. How we can obtain the patient’s data
•By asking
•Doing physical examination
•Reviewing client’s records
•Consulting supportive people
•Consulting health personals

25. Type of data
•Subjective data (symptoms)
•Obtain directly from the client by talking with
him
•Eg- itching, pain, worry, hungry
•Information supply by the family members,
significant others or other health
professionals

26. •Objective data (signs)
•Detect by observing as it can be seen, heard, felt
or smelled
•Gain physical examination and investigation
test
•Eg- blood pressure, body temperature, swelling,
low heamoglobin

27. Maslow’s hierarchy of needs

28. Physiological needs
•The need to breath
•The need to drink
•The need to eat
•The need to dispose bodily waste

29. Safety needs
•Physical safety
•Security of employment
•Family security
•Security of resources
•Health security

30. Love and belonging need
•Friendship
•Sexual intimacy
•Support and communication with family

31. Friendship

32. Sexual
intimacy

33. communication with family

34. Esteem needs
•Confidence
•Personal achievement
•Respect of others
•Attaining respect by others

35. Aging with confidence

36. Personal achievement

37. Respect of others

38. Attaining respect by others

39. Self actualization
•Creativity(නිර්මාණශීලීත්වය)
•Appreciate the life(ජීවිතය අෙය කරන්න)
•Feel closeness to others(අන් අයට සමීප බවක්
දැදන්)
•Motivated by values (වටිනාකම් වලින් දපලඹී ඇත)

40. Creativity

41. Appreciate the life

42. Feel
closeness
to others

43. motivate seniors to adopt healthy behaviors

44. What do we assess?
•Activities of daily living
•Gather data about the patient’s vital signs
•physical complaints

45. What do we assess…
•Visible body condition
•Medical history
•Current body functioning.

46. ADL
•Activities of daily living refer to the basic skills
needed to properly care for oneself and meet
one’s physical needs in six areas:
•eating, dressing, bathing, toileting, continence
and mobility

47. ADL…
•A person may be totally independent, require
minimal or moderate assistance, or be
completely dependent on another person in
each area.
•Health conditions that affect musculoskeletal,
neurological, circulatory or sensory systems can
also affect a senior’s ability to perform ADLs.

48. ADL…
•Why daily care important
•Unmet needs for help with activities of daily
living can lead to malnutrition, poor personal
hygiene, isolation, illnesses like urinary tract
infections (UTIs) and falls.

49. 2. Identification of problems
•The needs to be fulfill immediately
•High priority needs(ඉහළ ප්රමුඛතාවයක්)
•The need to be fulfill little be late
•Medium priority needs
•The needs to be fulfill later
•Low priority needs

50. 3. Planning
• understand the client’s problem and with them
look at a way of reducing it
•The plan must involve all those people who will
be using it(එය භාවිතා කරන සියලුම පුද්ගලයින්
ස්ම්බන්ධ්‍ කරන්න)
•It must involve the client
•Write the nursing interventions

51. 3. Planning…
•look at ways in which we can assist the client to
manage themselves as best as they are able
to(දස්වාදායකයාට තමන්ට හැකි අයුින් තමන්ව
කළමනාකරණය කර ෙැනීමට අපට උපකාර කළ හැකි
ක්‍රම දදස බලන්න)
•This is called giving them ‘active support’
•All staff assisting the client should be aware of the
plan

52. 4. Implementation
•In this phase care giver put the care plan into
action (ස්ත්කාර ස්ැලැස්තම ක්රියාත්මක කරන්න)
•Document the nursing interventions what
implemented

53. 5. Evaluation
•This is the phase when we should re look at the
plans and see if they are having the desired
effects
•නැවත සැලසුම් දදස බලා ඒවා අදප්ක්ිත ප්‍රතිඵල
ලබා ෙන්දන් දැයි බලන්න

54. 5. Evaluation …
•Eg problem is lack of mobility
•Plan- refer to the client for walking aid
•Implementation- do it
•Evaluation- client could mobilized with
minimal support, no adverse effects

55. Care plan fundamentals

56. Care plan fundamentals
•Three core questions the care plan should
answer:
•what
•why
•how
•

57. Care plan fundamentals…
•A nursing care plan should include:
•The What: What does the patient suffer
from? What do they risk suffering from?
•The Why: Why does your patient suffer from
this? Why do they risk suffering from this?
•The How: How can you make this better?

58. Types of care plan
•Daily care plan
•Weekly care plan
•Monthly care plan

59. Daily care plan
• daily care plan is a written or visual description
of each day.
• Its goal is to help ensure a person who need
others help and his or her caregiver has all their
needs met from day to day while staying as
active and engaged as possible (සියලු අවශයතා
සපුරාලීම සහතික කිරීමට උපකාර කිරීමයි.)

60. How do I create a daily plan
•Can use a paper template or an activity board.
• It can be written out in the style of a timetable,
•It can be created on an activity board using
visual prompts, pictures and cards for each
activity.(ක්‍රියාකාරකම් පුවරුවක නිර්මාණය කළ
හැක)

61. Why use daily care plan
•Certain daily events will always happen at a
certain time
•It anchors each day(එය සෑම දිනකම දමයි)
•Regular bedtime, get up at around the same
time each day and eat regular meals prepare
for next day

62. Why use daily care plan…
•It keeps everyone informed(එය සෑම දකදනකුම
දැනුවත් කරයි)
•Other carers, family or friends can also see
what’s happened earlier in the day and avoid
repeating the same activity or meal

63. A typical daily care plan
•Morning –
•Wake up, help with washing and dressing if
necessary
•Prepare and eat a heathy breakfast
•Morning activity – gardening, cooking, a craft
project
•Coffee and newspapers
•Quiet time to relax or take a nap

64. A typical daily care plan…
•Afternoon –
•Prepare lunch and eat
•Reminiscence(සිහිපත් කිරීම) – look at photos
together, listen to favorite music or do some life
story work
•Activity – household chores(දෙදර දදාදර් වැඩ)
•Take a break
•Prepare evening meal

65. A typical daily care plan…
•Evening –
•Watch TV, play a card game, run a bath

66. Example- daily care plan for patient with
dementia
• Morning
• Get up and perform a morning hygiene routine (brushing, toileting,
washing face).
• Make breakfast (have the person with dementia help as much as
he/she is able and wants to do so) and clean up breakfast together.
• Participate in an enjoyable art or craft project.
• Take a break and have some quiet time (this is a good time for
caregivers to do some meditation or reflecting).
• Take a walk or engage in another planned activity.

67. • Afternoon
• Eat lunch and clean up the meal together.
• Listen to some favorite old music or watch a favorite movie together.
• Look at family photos and talk about memories of the images.
• Try some physical activity, such as planting or weeding the garden.
• Visit with a family member, friend or neighbor.

68. • Evening
• Eat dinner and clean up together.
• Give a massage, start to wind down for bedtime.
• Help with nightly hygiene routines, such as a bath or shower, oral
hygiene and pajamas.
• Play a crossword puzzle or game.
• Read a favorite book passage and/or play some relaxing music before
turning in for the night.

69. Weekly care plan

70. Weekly plan
•Weekly plans are designs to achieve the
psychological, social and spiritual care addition
to the physical needs
•Aesthetic activities
•Shopping
•Eco visit

71. Some recreational activities
•Reading books, magazine and news papers
• Listening to the music
•Watching moves and television
• Painting and drawing
• Indoor and outdoor games
•Occupational therapy (knitting, crafting,

72. Aesthetic
activities

73. Eco
visit

74. Monthly plan
•This is covering the higher order needs of a
client
•Participating picnic
•Attending cultural events
•Gathering/companionship with friends,
relatives

75. Picnic

76. Cultural
events
(Easter
Sunday )

77. companionship

78. Case scenario 1 for care plan
• 82 years old Mr Simon is a retired employee, a widower in nursing
home for receiving care. His son and daughter are far to the nursing
home, visit the daddy once a month. His hearing and ability of vision
is very low. He does not take usual diet because of loss of taste. The
toileting habit of the Simon is not in routine, therefore he complain
some distension of abdomen. And also, he is unable to pass urine
therefore urine output is low. He has diagnosis of prostate
enlargement but not in treatment. Urine color is dark. He is on
medicines for high blood pressure. The mild ankle edema can be seen
in both legs. Due to the distension and leg cramping he complain
about difficult in falling sleep. He is worried about separated from the
family. He always complain the monotonous and loneliness of his life.

79. •Scenario 2
• 69 years old Margret is retired lady is in your work home
her husband has passed away 6 years ago. She has
suffering from diabetic mellitus 8 years and not on regular
treatments due to non compliance, also she is having
hypertension but not taken medical advice yet. She has a
wound in her left leg. Therefore, she cannot walk alone.
She is wearing spectacles for her reading and also far
vision. This lady is also on oral Antibiotics.
• Today she has not yet had her morning care and she looks
worried. When you call her, she gets angry and don’t like to
do anything. The days coming for Christmas in near future.