How Does a CNA Build a Plan of Care?

Building a care plan or care program is a part of the core curriculum of CNA training. These care plans help CNAs to stay focused and work according to the clients’ needs. These care plans help healthcare organizations to ensure continuity of care across nursing shifts, promote inter-professional collaboration by getting everyone on the same page, and meet documentation requirements for insurers and governing bodies.

Patient care programs or care plans help CNAs to think critically and evaluate which intervention is beneficial and which is not. 

What is a Plan of Care?

A care plan is written documentation or manifestation of the nursing process. The American Nursing Association defines it as “the essential core of practice for the registered nurse to deliver holistic, patient-focused care.”

The process involved in building a care program includes;

  1. Assessment: Collecting and analyzing data to gain a holistic understanding of the patients’ needs and risk factors. 
  2. Diagnosis: Using data, patient feedback, and clinical judgment to form the nursing diagnoses.
  3. Planning: Nurses develop short-term and long-term goals based on the assessment and assessment, ideally through the patient’s input. At this stage, nurses plan the interventions to meet those goals. 
  4. Implementation: Implementing nursing care according to the care plan, based on the patient’s condition and nursing diagnosis.
  5. Evaluation: Ongoing monitoring of the patient’s status and progress towards goals and modifying the care program or plan accordingly. 

Note that CNAs collaborate with Registered Nurses in developing care plans. However, it is essential to think logically before planning and implementing any interventions for the patients. 

How CNAs build a plan of care?

The CNAs build a care program or care plan by following these five steps;

Step 1: Assess the patient

The first step is to start by reviewing all relevant data, including but not limited to medical history, head-to-toe assessment, vital signs, activity and strength, conversations with clients and their families, observations from other care team members, and demographic information. CNAs in collaboration with RNs use this data to assess the client’s status in the following areas;

  • Physical, emotional, psychosocial, and spiritual needs
  • Areas for improvement
  • Risk factors

Step 2: Formulating nursing diagnosis 

Registered nurses mostly follow this step. However, CNAs are involved in it. After a thorough assessment, nurses identify the diagnosis of the patients-health problems (or potential health problems) that RNs can perform without the physician’s order and interventions. For example, acute pain, fever, insomnia, and risk for falls are all nursing diagnoses. The North American Nursing Diagnosis Association (NANDA) gives a complete list of nursing diagnoses, including definitions, features, and interventions that can apply to each nursing diagnosis. 

Step 3: Set goals for (and ideally with) patients

What are the desired outcomes, and how will the patients achieve them? Nurses and CNAs answer these questions based on the patient’s assessment, diagnosis, and feedback. Goals can be short-term, such as treating acute pain after surgery, and long-term, such as lowering the patient’s A1C with better diabetes management. After the nurses set goals, they prioritize them based on the urgency, importance, and patient feedback. Some nurses and CNAs also use Maslow’s hierarchy to prioritize patient’s goals.

Step 4: Implement nursing interventions.

Nursing interventions are the activities that CNAs perform to achieve patient’s goals and get the desired results. Some of the common examples of nursing interventions include assessing vital signs, preparing meals, dressing, providing bed baths, setting pain levels, etc. 

It is important to honestly and timely document the interventions that the CNAs perform. So, if an intervention is not working, it will be noted (and perhaps removed from future care plans). The most crucial part of the intervention stage is to report all reactions to the interventions accurately. Be as specific and objective as possible.

Step 5: Evaluate progress.

The evaluation is the final step of the nursing process. This is the stage at which CNAs, along with the other nursing professionals, look at their care plans and check to see if the program has “worked” in solving the patients’ health issues, concerns, etc. Remember that a good plan will work, and a bad one will not. CNAs and nurses see whether the care program or plan was effective or not-they look at subjective and objective data. Here your good documentation will work. For example, suppose a patient was incontinent and wasn’t so until a recent illness. In that case, the nurse might try a timed program approach to help the patient regain control.

Making a care program does not end here. It continues till the desired outcome is achieved, and a significant amount of improvement is observed. Some patients get discharged from the hospital with a care plan that the home health CNAs must follow and evaluate accordingly. 

Thoughts to ponder

Building a care program for a client is not a one-person show; instead, a collaborative team approach involving other healthcare team members is needed to make an effective and patient-oriented care plan. It would not be erroneous to say that building programs mean inter-professional collaboration. Not only that, but the patient is the center of this program; therefore, he and his family should be involved in this whole process of program building. 

Essentially, this care program needs to be monitored and updated regularly to foster the best possible care and client satisfaction. In short, this patient care program is a resource for nurses to get all the information they need in one place.

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