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Participate in the
Implementation of
Individualised Care Plans
Aims and Objectives
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Plan work activities according to an individualised
plan
Establish and maintain appropriate relationships with
clients and carers
Provide and monitor support according to the
individualised plan
Contribute to ongoing relevance of the individualised
plan
Respond to situations of risk to the client within work
role and responsibilities
Complete documentation and reporting
Planning work activities
Organisational policies and
procedures
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Policies set out the general standards of
service for that agency to achieve- must be
accessible to all staff, clients and other
interested parties.
Procedures are specific written instructions
that explain what a staff member is to do,
step by step in a particular situation.
It is YOUR responsibility to be familiar with
the P & P within your work
Individualised Plans
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Also called Care Plans, Service plans, Client
plans.
A care plan is an individualised plan of care
and gives directions for staff to follow in the
provision of care.
The plan details the care requirements that a
person needs on a daily basis. This type of
document is generally used in long term care
because it replaces the need to detail all care
given each day in the resident’s case notes.
Individualised Plans
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Provide an accurate, concise notation of the
residents’ current condition.
The care plan provide information about the
resident’s goals and care needs.
The care plan is a recipe about how the care
needs to be provided.
The notes provide baseline information on
which to record any improvement or
deterioration in the resident’s condition.
Individualised plans
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The record provides evidence of care. The records will provide
information about what care was provided, by whom, when and
any comments from the resident, doctor, or significant other.
The care plan is a dynamic document, meaning that it changes
regularly dependent on the needs and changes in the resident.
It should be used and reviewed on a regular basis. The care
plan is a care tool to direct and guide staff in how the care
needs to be provided to the resident.
Care plans need to be individually tailored to the care needs of
the individual, there is no magic formula to suit all residents,
however there are some basic guidelines which you can follow
in order to formulate the care plan.
The Nursing Process and Care
Planning
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Assessment
Planning
Implementation
Evaluation
Assessment
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Observation of their needs by sight, hearing,
touch and smell
• Communication with other members of
the team to make accurate assessment of the
care needs of the resident. Sometimes care
workers need to provide different care
activities to the same resident. Either
because the resident favours a particular care
worker of that the worker has expert
knowledge.
Assessment
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A thorough assessment must be compiled in
a variety of areas to determine the long term
care needs and goals of client care. Areas of
assessment include the following:
Physical care needs
Psychological care requirements
Socialisation needs of the individual
Spiritual needs
Assistance to maintain their personal affairs
Relationships with family and others
Assessment forms currently
used
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Personal profile
Communication Assessment
Social and emotional needs
assessment
Nutrition and Hydration
Assessment
Mobility Assessment including
falls risk and manual handling
assessments
Personal hygiene
assessments, physical
assessments oral hygiene
assessments
Toileting assessments
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Continence assessments
Bladder and bowel
Psychogeriatric Assessment
scale (PAS)
Behaviour Assessment – Verbal,
Wandering, Physical agitation
Cornell depression scale
Medication Assessments
Complex care needs
Assessments – Pain scales,
Waterlow scale for skin
integrity, diabetes Assessment
etc
Planning
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Once the assessment is completed goals of
care need to be developed. The goals
determine whether a client will be able to
restore or maintain their current level of care.
The goal of care may be to improve the
person’s current ability or simply to preserve
their current function and level of
independence.
Sample Care Plan
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Impaired Verbal Communication
Identified need/Problem:
Impaired verbal communication related to:
Decreased oxygen to the brain.
Unable to speak English
Impaired articulation.
Disorientation.
Loose association of ideas,
Inability to speak sentences.
Slur or stutter.
Sample care plan
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Goal:
Resident will communicate and
participate in activities of daily living
using either verbal or non verbal modes.
Assess contributing factors. Note whether the problem
is expressive (loss of speech), Sensory (unable to
understand words, Conduction (slow comprehension)
or Global (loss of comprehension and speech).
Implementation
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The nurses actions
Like a written handover, how everyone
should be carrying out the care.
Ensures that everyone is doing the
same level of care
Sample care plan
Interventions:
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Determine native language spoken and cultural background.
Assist patient to establish means of communication.
Listen carefully to patient on verbal expressions.
Validate meaning of non-verbal communication.
Maintain eye contact.
Keep communication simple.
Plan for alternative methods of communication (written instructions
or picture boards).
Maintain a calm unhurried manner- allowing time for the resident to
respond.
Evaluation
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This includes your monthly, two
monthly evaluation of how the person r
the care is meeting their goals and
preferences
It assists to determine if the staff are
meeting the needs of the client.
Evaluation
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See ACFI Checklists
What are the Care Worker
responsibilities
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READ the individualised care plans
Evaluate them regularly
Input into the care plans from your
individual knowledge of the client
Contribute to case conferences and
feed back the effective actions you use
Appropriate relationships
with clients
Communication
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Introducing yourself
With client
With staff
With management
With relatives and friends
Documentation
Introducing yourself
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Be polite.
Use open communication skills.
Be genuine in your motivation.
Provide name, position and the task you want
to carry out.
Wait until you have consent.
Respect the person’s right to refuse.
Check your own emotions, feelings,
frustrations before you enter the room.
Communication with clients
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Respect basic human rights
Be approachable
Sometimes need to make the first move to
communicate
Develop a trusting relationship
Clear, calm, open language and body
language.
Be culturally sensitive.
Allow clients to make as many decisions as
they can.
Communication with staff
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Be understanding of the mood/stress of other
staff
Be willing to work with them
Use the “power with” not the “power over”
principle
Be willing to learn from others, instead of
right every time.
Work cooperately, plan and talk all shift.
Communication with
Management
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Understand that reporting on is part of your
job role.
Find convenient times to report.
How urgent is the incident/ problem?
Give your opinion in an appropriate setting.
Be respectful of the position your manager
holds.
Provide clear communication or written
documentation.
Appropriate relationships with
carers
Communication with Relatives
and Friends
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Find out the policy on what you can
communicate and who can
communicate the information.
Develop a rapport with relatives but do
not breach confidentiality.
Communicate what your job role allows
but do not communication information
outside of your scope of practice.
Confidentiality and Privacy
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Personal information, which is obtained while caring
for a client, is confidential. The client has the right to
decide who to share this information with.
Confidentiality applies to information that a client or
other care worker tells you verbally or gives you in
writing. It also applies to things that you learn
through observation. All information in a person’s
health care record is confidential and may not be
disclosed without permission from the client or their
guardian. Information may be shared with other
relevant health and aged care workers when they
need the information in order to provide appropriate
care.
Maintaining Confidentiality
A carer has a moral duty and often legal obligation to protect the privacy
of an individual by restricting information obtained in a professional
capacity to appropriate personnel and settings, and to professional
purposes.
A nurse must, where relevant, inform an individual that in order to provide
competent care, it is necessary for a carer to disclose information that
may be important to the clinical decision making by other members of a
health care team.
A carer must, where practicable, seek consent from the individual or a
person entitled to act on behalf of the individual before disclosing
information. In the absence of consent, the nurse uses professional
judgement regarding the necessity to disclose particular details, giving
due consideration to the interests, well–being, health and safety of the
individual and recognising that the carer is required by law to disclose
certain information.
Privacy
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In the context of Aged care and Health
care privacy means discretion and
secrecy
Appropriate conversation
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Need to socially appropriate at all time.
Need to direct your conversation at the
clients needs or carers needs- NOT YOUR
OWN.
Do not swear, complain, or give out personal
or sensitive information.
Be friendly with your work mates but
remember they are not your best friend.
Do not reveal personal information to
colleagues.
Supporting Independence
Contributing to the
individualised plan
Problem solving skills
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1. Define the problem
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2.Generate Ideas
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3. Investigate solutions
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4. Choose an option
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5.Plan to act
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6. Evaluation
Use the problem solving
technique to solve the following
problem
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The co-worker that you are teamed with likes
to spend time talking to the clients, and
leaves you the bulk of work.
It also means that you have trouble getting
to know the clients you work with.
What could you, and your work team, do to
resolve this situation?
Identifying risks to the client
Providing care
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Assessment
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Observation
Questioning
Consultation
Medical History
Physical ability
Lifestyle choices
Family history and
dynamics
Past experiences
Social contacts
Risk Assessment
Scope of Practice
Role of an Aged Care Worker
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Multi skilled
Flexible in work practices in care delivery
Work as part of the multi-disciplinary team
Participate in planning & delivery of care
Abide by the mission statement & job
description
Responsibilities include- OHS, documentation,
provision of care.
Role & Responsibility
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To observe (collect physical data) the patient;
Report to supervisor/ RN any change in a pts
condition;
Other areas the AIN is responsible for
reporting include: equipment faults, safety
hazards, need for supplies, incidents/
accidents, breaches in confidentiality,
absences from duty/ breaches in duty of
care- abuse.
What is expected of you as an
AIN
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Fulfils the duties of the job description
Technical skills (i.e.. BP) communication
skills (interaction with staff & clients)
Time management
Team work
Documentation skills
Personal attributes
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Conscientious
Trustworthy
Patient
Thorough
cooperative
Respectful
Caring
Honest
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Accurate
Empathetic
Reliable
Flexible
Organised
Adaptable
Flexible
Passionate
Duty of Care
Rights of workers
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Safe work environment
Free from harassment
and discrimination
Work conditions and
wages in accordance
with IR laws
EEO
Accountability & Responsibility
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Duties as per job description
Completion of specific tasks at the
required standard in a reasonable time
frame.
Accountable means you are answerable
for the things you do.
Who are you accountable and
responsible to?
Activity
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Think of an organisation you know and
develop an Organisational chart which
indicates who you report to.
Reporting to your Supervisor
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Be professional –
Provide accurate Data eg: results from tests: UA
Provide objective not subjective reporting
Be proactive and seek a time to talk to your Supervisor
that is convenient.
Allow that the Supervisor, while knowing your role, may
not be aware of every part of the job.
When reporting provide some solutions that will work.
Document your concerns so the Supervisor has something
to work from.
Carry out the instructions you are given and report back
their results.
Reporting inappropriate
behaviour
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Clients
Use data collected over time,
Relate specific incidents or
behaviours of concern
Report the time frame of the
behaviour
Report any triggers of the
behaviour
Use a non judgmental
approach
Always maintain confidentiality
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Colleagues
Provide accurate information
Be non judgmental when
reporting
Provide time and location
incidents take place
Always report privately
Have an incident report written
out so the the Supervisor has
all the facts
Incident reporting
Completing Documentation
Care Records
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Also known as:
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Case notes
Client file
Residents notes
Commenced on
admission
The purpose is:
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Centralised record for all
to document
About care
Information about the
client
Information contained in the care
record
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Progress notes
Observation charts
Care Plans
Admission, discharge and transfer notes
Medical history and doctors notes
Progress notes
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Ongoing record of
the older persons
day to day care and
progress
Must document only
facts, not
interpretations of
events
Progress notes:
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Ensure quality
Assist when making
assessment
Ensures the worker
works within the
care plan
Continuity of care
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Accountability
Evaluating care
The process of
reflecting,
monitoring and
improving care
delivery
Guidelines for report writing
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Must be written on all
clients at least once a
day
Plus exception report
writing
The report must contain
the time and date, must
be signed and
designation recorded
Report writing
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Permanent records
Factual
Accurate
Legible using black
or blue ink
Use professional
language
Be brief, simple and
to the point
Principles of report writing
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Record promptly or
ASAP after event has
occurred
Use the 24 hour clock
Only use approved
abbreviations
Correct spelling and
grammar
Do not leave any spaces
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Check previous entries
Make corrections
properly
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Rule a line through the
error
Write the correction and
initial your entry
Do not erase or use
whiteout
Ensure the original entry
can be read
Case scenario
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You have just finished caring for Mrs. Jones
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You have showered her and she dressed herself
She was happy and chatty
You noticed a red spot on her lower R leg
She ambulated into the bathroom with a PUF
She ate a small amount of breakfast and is now
sitting in the lounge room
Document in the progress notes
Confidentiality and access to
records
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Client notes are
confidential and access
is restricted to:
The storage of records
must be locked to
maintain confidentiality
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Designated staff
The clients ensuring
someone is with them
e.g.. RN when they read
their notes
Refer to Policy and
Procedure of facility
Reasons for documentation
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Legal requirement
Funding
Management systems, staffing and
development
Resident lifestyle
Physical environment and safe systems
Types of documentation
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Observation chart
Bowel chart
FBC
Accident forms
Care Plans
Admission data
Restraint charts
Complaints form
Accident/Incident forms
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Legal requirement
Identifying risks
Hazard control
Monitoring
behavioural trends
Monitoring work
practices
Case Scenario
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You discover Mrs. Campbell lying on the bathroom
floor at 1650 hours
You left her sitting by her bed 5 minutes previously
She has sustained a skin tear 3cm to her L forearm
and has a bruise on her R knee
You stay with the client and buzz for assistance
The RN arrives and asks you to record a set of obs,
dress the skin tear and complete an incident form
The RN contacts the DR and Mrs. Campbell's
daughter
Complete the form
Verbal reports
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Given at the start of
each shift –
handover or
changeover
Staff finishing
should also report
any tasks or care
not completed
Group Work
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Break into 5 groups
List 4 changes you might observe when
caring for a client
Each group to pick 1 system and report back
to the group
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Integumentary system
Circulatory system
Urinary system
Digestive system
Musculoskeletal system