Care planning

from Wikipedia, the free encyclopedia

In professional health and nursing care and care for the elderly, care planning is a section of the care process that, together with the care documentation , helps to structure, systematically record, carry out and evaluate targeted care activities. The result of the care planning is the written care plan , which provides the care-relevant information for the implementation of care interventions for all those involved in care. Within the care planning, care goals are defined based on the care needs individually tailored to a care recipient , and the care measures necessary to achieve the desired care result are planned and documented.

Definition of terms

Graphical representation of the maintenance process according to Fiechter / Meier

Care planning is an instrument for the concrete implementation of the care process. It enables goal-oriented, systematic, structured and logical action and is therefore different from lay care. They and also the care documentation are often equated with the nursing process in everyday German-speaking nursing; this can mainly be attributed to the lack of teaching of nursing science and academic fundamentals during and after nursing training. In the basic statement of the medical service of the central associations of the health insurance companies , it is stated that due to an inadequate communication of the connection between the nursing process and the respective nursing documentation in nursing practice, it is assumed that with the mandatory completion of the documentation system by legal requirements, the nursing process and thus also the nursing planning as such takes place.

Position of care planning in the care process

Nursing planning is part of the internationally established working method of the nursing process as the basis for nursing action. This is an abstract method for problem solving and an analytical model of action, based on cyclically repeating and mutually influencing phases. The process, also known as the nursing control loop , is based not only on nursing scientific work but also on findings from systems theory , cybernetics and decision theory . Models with four, five or six phases are widespread, the terms used for the individual phases are not uniform, but all models include the step of care planning. The planning phase is embedded after the information collection or care assessment and the care diagnosis or the recognition of resources and care problems. Nursing planning serves as the basis for action for the next step of nursing intervention, the actual implementation of nursing.

Tabular comparison

In the six-phase nursing process model according to Fiechter and Meier, which is widespread in Germany, nursing planning, the determination of nursing goals and nursing planning is divided up again, but according to Yura and Walsh this separation has no effect on the care result itself. Due to the work of Monika Krohwinkel , the sharper definition of terms and the logical superiority, however, the four-phase model is gaining increasing influence in German-speaking care.

The position of nursing planning in the various nursing process models can be compared in a table:

Four-phase model Five-phase model Six-phase model
Assessment (information gathering and nursing diagnosis) Assessment (information gathering) Information gathering
- Diagnosis (nursing diagnosis) Recognition of resources and care problems (analogous to care diagnosis)
Planning (care planning) Planning (care planning) Definition of goals (first part of care planning)
- - Planning of measures (second part of care planning)
Implementation / intervention Implementation / intervention execution
Evaluation Evaluation Evaluation

For a successful implementation of the planning, the initial assessment to determine the specifications and the repeated evaluation for feedback from the nursing process are decisive. Without the regular correction of the planning, the implementation may start incorrectly and later the planning becomes outdated as the process progresses so that only a new planning provides a valid working basis for the implementation. As long as the information collection follows the implementation without delay, this divergence of process and plan can be avoided by progressive correction of the planning on the basis of the information collection.

Elements of care planning

Care goals

In the first step of the care process, the information collection or assessment , all available care-relevant information is recorded, which is used to determine the care needs of the care recipient. In addition to the so-called master data, this includes the physical and psychological condition as well as the lifestyle of the person in need of care. Checklists and various nursing assessment tools can be used to collect further data. Additional sources of information include information from relatives, previous care plans, medical history, and observations from other professional groups. Building on this, maintenance problems and resources are determined and documented in order to determine the current status. Areas of life in which no nursing intervention is necessary therefore have no goal orientation and are not included in nursing planning in practice. On the basis of the identified care problems, the person in need of care, the caregiver or relatives define care goals that are based on the focus of the care problems identified in the anamnesis and determine corresponding care priorities. These care goals represent the target state. According to Fiechtner and Meier, a distinction can be made between long-term goals that are to be achieved in the long term and short-term goals that can be achieved in the foreseeable future or that can represent a partial step towards a long-term goal. Regardless of this classification, all goals should be formulated in such a way that they describe a realistic, achievable and objectively verifiable care result. In addition to a concrete description of the goal, this includes setting a time frame for checking whether the goal has been achieved. The content of a care goal can be, for example, the behavior, skills and abilities, the development and knowledge of the person in need of care or their physical condition or measurable changes.

Examples of a defined care goal according to the model of supportive process care widespread in Germany can be:

  • AEDL care for yourself: Ms. M. washes her face in one week.
  • AEDL food and drink: Mr R. gained one kilogram within a month.
  • AEDL occupy yourself: Mr. After moving, K. would like to find a meaningful job in his new environment.

Maintenance measures

In order to achieve the defined care goals, the caregiver and the person in need of care plan the necessary specific care measures together. These actions, also known as nursing intervention, are defined as the application of nursing and interpersonal skills, the instruction and counseling of the care recipient, and the organization and delegation of the work. In addition to the needs and resources of the person in need of care and their relatives, the institutional framework such as the number of staff and care products are taken into account during planning. The formulation of the measures must be precise, unambiguous and understandable, the parameters type, quality and time intervals of the measures must be described; as a motto is also used here: "Who, what, with what, when, how often". If care standards or expert standards are defined, it is sufficient to state them, but they do not replace the obligation to individual planning, but make it easier to plan measures in the context of frequently occurring care problems. In Germany, the brief descriptions of complete takeover (VÜ), partial takeover (TÜ), support (U) as well as advice, guidance and supervision (BA) for specifying the scope of the Maintenance usual and correspond to the underlying legal requirements.

Examples of care measures based on the care goals:

  • AEDL caring for yourself: Instructions for washing your face as part of your morning body care routine at 7.30 a.m. by the caregiver.
  • AEDL Eating and Drinking: For all meals, in consultation with the kitchen, prepare and offer preferred meals and additional snacks at 3 p.m. and 10 p.m.
  • AEDL Getting busy: Accompaniment and transport to the senior sports group on Wednesday at 4:00 p.m. and to the senior citizens' drink on Saturday at 10:30 a.m. by the community service provider. Regularly inform Mr K. and relatives about additional offers through the social service.

If the care result in the final evaluation does not match the target, the reasons for this are examined. Possible reasons can be incomplete information gathering, a misjudgment of the initial situation or the need for care, setting the care goal too broadly or planning inappropriate care measures. The care plan is then adjusted to the actual situation, care goals achieved lose priority, new goals or goals that have not been achieved are formulated and planned.

Four basic forms of care plans

As early as 1981, the Swiss nursing scientists Verena Fiechter and Martha Maier differentiated didactic and practical nursing plans in their classic nursing plan; They also differentiated between standardized and individual care plans.

The two pioneers in nursing care planning in German-speaking countries have not yet combined these two distinctions. This only happened in 1998, when Reinhard Lay developed a four-field scheme : four basic forms of care plans .

didactic practically
standardized Standardized didactic care plan
  • created for teaching purposes
  • does not refer to a specific individual, but to a category of people in need of care

Examples: Didactic care plans for caring for people at risk of falling, caring for newborns, care for diabetes mellitus, care after a femoral neck fracture, etc.

Standardized practical care plan
  • created for practical maintenance
  • does not refer to a specific individual, but to a category of people in need of care

Examples: care standards, e.g. B. for oral care, for monitoring after endoscopic examinations, for the administration of tube feeding etc.

individually Individual didactic care plan
  • created for teaching purposes
  • refers to a fictional individual whose concrete life situation is constructed and described

Example: care plan that is created in class using a specific case study

Individual, practical care plan
  • created for practical maintenance
  • relates to a real client and is usually created together with them

Examples: care plan for a specific patient in the hospital or for a new resident in an inpatient care facility for the elderly

Four-field scheme Four basic forms of care plans (Lay 1998).

Development of an individual, practical care plan

An individual, practical care plan has the character of a care ordinance and is binding for everyone involved in care. In the individual, practical care plan, the phases of the care process following the assessment are prepared in written or virtual form, usually the identified care problems, skills and resources, care goals, care measures and their review are assigned to one another. The storage of the care plan as a care plan serves, on the one hand, to ensure professional continuity of the care in the course of the care and grants all those involved in the care access to the necessary information to carry out the care in practice. The individual, practical care plan is one of the central documents within nursing documentation systems , on the basis of which the target / actual state can be objectively assessed during quality control (evaluation) and the service provided can be presented transparently. As part of this care plan, all care measures carried out should be documented promptly and locally with a hand sign or signature of the caregiver. If measures are not carried out, this must also be documented, stating the reasons. This is used to make the care service comprehensible. This satisfies legal requirements, or the quality of care is also made verifiable in the legal sense of the preservation of evidence.

Example: Typical structure of an individual, practical care plan in a simplified representation

Problems, skills, and resources Care goals Maintenance measures Evaluation
Problem: Ms. M. cannot carry out personal hygiene on her own. Skills: Ms. M. can use her right hand without restrictions. Resources: Ms. M. attaches great importance to a well-groomed appearance. Ms. M. will wash her face in a week. Instructions for washing the face as part of the morning body care at 7.30 a.m. by the caregiver. The goal was achieved.

Formulation aids for creating an individual care plan

In nursing practice, there are sometimes formulation difficulties in nursing planning. As a result, the formulations in the care plans are incomplete or not meaningful. Standardized care classifications can provide support here. You have classified nursing problems / nursing diagnoses, nursing goals and / or nursing measures.

The best-known care classification systems in German-speaking countries are as follows:

Worldwide there are numerous other nursing classification systems which describe nursing diagnoses, goals and measures and which could be used for nursing process documentation.

Position of other professional groups in care planning and documentation

The coordination and consultation with other professional groups, for example doctors, speech therapists or physiotherapists, is part of the nursing activity. With the documentation of the nursing process, it offers this access to the nursing-relevant information, decisions and actions. The respective orders such as the prescription of medication or treatment care are not part of the actual care planning, but are only recorded in the care documentation system or the care plan. Basically, the other professional groups should be given access to the documentation so that they can independently enter and sign the corresponding orders and get an overview of the nursing process or can document their own observations that have an influence on the nursing measures in the nursing plan. Typical documents in this context are, for example, the temperature curve , which is used by nurses and doctors to monitor the progress of the vital signs, or the wound documentation in which the wound treatment can be coordinated with the doctor or wound manager.

literature

  • Birgitt Budnik; Kreikenbaum, Jens: Care planning made easy . With the collaboration of Reinhard Lay ; Elsevier - Urban & Fischer Verlag, Munich, 7th edition 2014, ISBN 978-3-437-26954-7 .
  • Verena Fiechter, Martha Meier: Care planning. A guide for practice. Basel, Recom, 1993, 9th edition, ISBN 3-7244-8574-3 .
  • Friedhelm Henke, Christian Horstmann: Care planning precisely formulated and corrected . Practical work aids for teachers and students, nursing process-oriented training including exercises. Kohlhammer, Stuttgart, 2nd edition 2010, DIN A4, 119 pages, EUR 17; ISBN 978-3-17-021668-6 .
  • Friedhelm Henke: Formulation aids for care planning Central care documentation with information from the MDK guidelines. Kohlhammer, Stuttgart, 5th edition 2010, ISBN 978-3-17-021560-3 .
  • Manfred Hülsken-Giesler: The access to the other: For the theoretical reconstruction of professionalization strategies of nursing action in the field of tension between mimesis and machine logic. Volume 3 of Nursing Science and Nursing Education, V&R unipress, 2008, ISBN 3-89971-373-7 .
  • Medical service of the umbrella organizations of the health insurance companies V. (Hrsg.): Basic statement of the care process and documentation - recommendations for action for professionalization and quality assurance in care. April 2005. Available online at: Care Process ( Memento from February 28, 2013 in the Internet Archive ) (PDF; 1.7 MB).
  • Nicole Menche: Revision Course Care Today. Elsevier, Urban & FischerVerlag, 2006, ISBN 3-437-27840-1 .
  • Kerstin Menker: Nursing Theory and Practice. Elsevier, Urban & FischerVerlag, 2006, ISBN 3-437-47930-X .
  • E. Rath, U. Biesenthal: Care planning and care documentation. In: Pflegezeitschrift , Kohlhammer, Issue 12/1994, Vol. 47, ISSN  0945-1129 .
  • Reinhard Lay; Bernd Menzel: Care planning - breakdown assistance for a nursing procedure. In: Pr-InterNet, PflegePädagogik. Issue 2/1999, pp. 43–50.

Individual evidence

  1. ↑ Friedhelm Henke, Christian Horstmann: Nursing planning precisely formulated and corrected. Practical working aid for teachers and students. Kohlhammer, Stuttgart, 2nd edition 2010, ISBN 978-3-17-021668-6 , pp. 11-12
  2. ↑ Birgitt Budnik, Reinhard Lay: Care planning made easy: for health care and nursing. Elsevier, Urban & FischerVerlag, 2005, ISBN 3-437-26952-6 , pp. 20-22
  3. ↑ a b c d Medical service of the umbrella organizations of the health insurance companies. V. (Hrsg.): Basic statement of the care process and documentation - recommendations for action for professionalization and quality assurance in care. April 2005. Available online at: Nursing Process ( Memento from February 28, 2013 in the Internet Archive ) (PDF; 1.7 MB)
  4. ^ Yura and Walsch, quoted in Maria Mischo-Kelling, Henning Zeidler : Internal Medicine and Nursing. 1992, 2nd revised. Ed., Urban and Schwarzenberg, Munich, ISBN 3-541-13892-0 , pp. 2-6
  5. ↑ Manfred Hülsken-Giesler: Access to the other: For the theoretical reconstruction of professionalization strategies of nursing action in the field of tension between mimesis and machine logic. Volume 3 of Nursing Science and Nursing Education, V&R unipress, 2008, ISBN 3-89971-373-7 , pp. 319-320
  6. ↑ Nicole Menche: Revision Course Care Today. Elsevier, Urban & FischerVerlag, 2006, ISBN 3-437-27840-1 , pp. 39-40
  7. ↑ Cf. on this Kerstin Menker: Pflegetheorie und -praxis . Elsevier, Urban & FischerVerlag, 2006, ISBN 3-437-47930-X , p. 104 or Dagmar Wiederhold: AEDL checklists. Elsevier, Urban & FischerVerlag, 2007, ISBN 3-437-28100-3 , pp. 3–5
  8. ^ Jean Heath, Gladys M. Law: Customized Nursing. A practical introduction to the topic “Nursing process - what is it?”, Evaluation, quality management, nursing planning in the field of nursing. 1988, DBfK (Ed.), P. 32
  9. ^ A b c E. Rath, U. Biesenthal: Care planning and care documentation. In: Pflegezeitschrift, Kohlhammer, Ed. 12/1994, Vol. 47, ISSN  0945-1129 , pp. 2–13
  10. ↑ a b Kerstin Menker: Nursing theory and practice. Elsevier, Urban & FischerVerlag, 2006, ISBN 3-437-47930-X , pp. 103-104
  11. ↑ Maria Mischo-Kelling, Henning Zeidler: Internal medicine and nursing. 1992, 2nd revised. Ed., Urban and Schwarzenberg, Munich, ISBN 3-541-13892-0 , pp. 2-6
  12. ^ A b Nicole Menche: Repetition Care Today. Elsevier, Urban & FischerVerlag, 2006, ISBN 3-437-27840-1 , pp. 40-41
  13. ↑ Fiechter, Verena; Maier, Martha (1981): Care planning. A guide for practice. Basel: Rocom, pp. 54-61.
  14. ^ Lay, Reinhard, unpublished text, quoted from: Lay, Reinhard; Menzel, Bernd: Care planning - breakdown assistance for a nursing procedure. In: Pr-InterNet, PflegePädagogik, Edition 2/1999, pp. 43–50.
  15. ↑ Reinhard Lay, unpublished text, quoted from: Reinhard Lay, Bernd Menzel: Pflegeeplanung - Breakdown assistance for a nursing procedure. In: Pr-InterNet, PflegePädagogik. Issue 2/1999, pp. 43–50.
  16. ↑ Bartholomeyczik, S. and M. Morgenstern (2004). “Quality dimensions in care documentation - a standardized analysis of documents in nursing homes.” Pflege 17 (3): 187–195
  17. ↑ Wieteck, P., Ed. (2013). Practice guidelines for care, planning and documentation based on care diagnoses of the ENP classification. Kassel, RECOM Verlag
  18. ^ NANDA International (2013). NANDA I Nursing Diagnoses Definitions and Classification 2012–2014. Kassel, RECOM Verlag
  19. ↑ Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (Eds.). (2013). Nursing Outcomes Classification (NOC): Measurement of Health Outcomes (5th ed.). St. Louis, MO: Elsevier
  20. ↑ Bulechek, GM, HK Butcher, et al. (2013). Nursing INterventions Classification (NIC), 6th edition. St. Louis, Missouri
  21. ↑ Kerstin Menker: Nursing theory and practice. Elsevier, Urban & FischerVerlag, 2006, ISBN 3-437-47930-X , pp. 105-108.