A Guide to Develop a community nursing care plan with ndis

community nursing care plan for disable and elders

A nursing care plan is a strategic approach to streamline the nursing process. These plans facilitate effective communication among nursing staff working in hospital or aged care center. 

The article aims to provide information about the nursing care plans for the NDIS participants. Therefore you will gain knowledge on the community nursing care plan for pain, COPD, asthma, and palliative focusing on the NDIS participants.  


What is a community nursing care plan?

A community nursing care plan, facilitates standardised, evidence-based, holistic care for the individual, family, or community. 

What is a nursing care plan? As part of a nursing care plan, the role of a community health nurse is defined by how you’ll help a person meet their assessed needs so they can remain at home. Together, you should prepare a care plan for the individual and ensure that they understand and agree to it. At least once every 12 months, you should review the plan. 


In a community nursing care plan, the following is outlined: 

  • the individual’s home care needs 
  • the required services to meet the need 
  • when and who will address the need 


The care plan is prepared for the home nursing service for the NDIS participants. And the community nurse role assigned to care for the participants should be an NDIS registered nurse. 


Nursing care plan for COPD

As part of the COPD Action Plan, a healthcare professional will evaluate the early signs and symptoms of a flare-up or worsening of symptoms. A written plan describes what to do in the event of an outbreak. 

As COPD increases or symptoms worsen, a GP or specialist completes an Action Plan outlining the best course of action. Review your COPD Action Plan annually. 

NDIS individuals who have recently been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) should review COPD the basics. 


What is included in the nursing care plan for COPD?

The nursing care plan for the COPD includes a detailed assessment of, 

  • Diagnostic tests 
  • Treatment 
  • Diet 
  • Exercise 
  • Pulmonary Rehabilitation 
  • Vaccinations 
  • Flare-ups (exacerbations) 
  • COPD medicines 
  •  Therapies 


Those living under NDIS nursing should have a care plan that includes:

  • personal goals, needs, and preferences 
  • the required medical attention 
  • schedule, such as when and how often medical attention is provided 
  • emergency assistance or medical attention from the caretaker 

The nursing care plan is reviewed quarterly in consultation with specialists and NDIS participants. 


Mental health nursing care plan

Mental health care plans in nursing are available for any NDIS mental health patients who require more than three health professionals and whose symptoms last longer than six months will benefit from the care plan. 

You and your doctor can decide which services are best for your needs using your care plan. 

Using a care plan, you can understand what each healthcare team member is responsible for and when they need to be involved. 

Keeping your care plan up to date is essential to ensure that it addresses your needs. 

People with mental illness working with multiple healthcare professionals are referred to as people with mental health care plans. 

The care plan for mental health patients explains which health professionals will support them and when treatments are provided. In addition to counselling, your care plan might include how to handle a situation.  


What is to be included in the mental health care plan?

Your doctor will draw up a mental health care plan after agreeing on the goals you wish to achieve and the support you need. Together with your doctor, you’ll determine: 

  • How to address your mental health concerns? 
  • Whether you require medical, physical, psychological, or social assistance? 
  • Your desired outcome? 
  • A recommended course of action. 


Nursing care plan for asthma

You need an asthma action plan if you have asthma. You will be able to do the things you want when you take control of your asthma. 

Asthma medications fall into two main types – relievers and preventers. 

Your doctor will recommend a suitable inhaler device for your needs. 

Whenever a preventer is prescribed, you must take it as directed. Taking preventer medications that are stronger than you need will not help you. 

Taking a relief medication more than twice a week should be discussed with your doctor to develop a proper patient care plan. 


What is to be included in the asthma care plan?

Asthma is a chronic inflammatory disease that may be life-limiting and even life-threatening.  

With your doctor’s help, you will create an asthma action plan to help you manage your asthma.  

In addition to health advice, it explains what you should do if your asthma becomes unstable and you need medical assistance. 

You should review your asthma action plan every six months if you suffer from severe asthma attacks. 

A plan for asthmatic management includes the following:  


  • Your regular asthma medications and how often you should take them daily are listed in this guide to caring for your asthma day-in and day-out.  
  • What to do if your asthma gets worse or is severe, and what to look for (asthma aid). 
  • There are asthma symptoms that are severe enough for you to need prompt medical attention, so clear written instructions for you or your caretaker to follow during emergencies. 


 Nursing care plan for pain

Pain is natural to occur in both men and women. And as we age, experience goes high, especially in the case of female participants. 

Based on the severity of pain, a sudden sensation may be localised or a widespread pain in your body. 

How a person copes with pain can affect a person’s quality of life?  

So far, the pain has been identified into two streams: Acute and Chronic.  

Injuries and medical conditions may cause acute pain. It is sudden and short-lived. 

However, chronic pain can last for much longer than expected. Generally, chronic pain is likely to last for over three months. 

Common nursing intervention for pain includes medicines, acupuncture or a massage, and physical therapy, which are stated in the nursing care plan of the patients.  


What is to be included in the pain care plan?

In any care centre, though the caretakers are always attentive to any NDIS patient, they still need to know about the patients’ painful situations.  

Therefore, the following are included in the pain care plan of any NDIS patient:  

  • Previous pain level (chronic or acute) assessment, response to treatment, and treatment effects at regular intervals. 
  • Minimise the impact of pain, coordinate care, adjust the environment, and encourage the patient to rest or sleep. 
  • Regularly administer medication to the patient; adjust dosage in response to the patient’s reaction; administer pain medication before a painful procedure. 
  • Manage the pain by adding medicine, rotation, or change in treatment.  
  • Addition of physical exercise, yoga, or therapy.  
  • Evaluate and assess the risk factors associated with pain. 


Palliative care nursing care plan

Whether you are dying of cancer, Alzheimer’s disease, or a chronic illness, palliative care is a vital part of your care.  

Different stages of illness may require palliative care. Palliative care may be needed for a short time, intermittently or regularly over months or years. Most patients who receive palliative care will be approaching the end of their lives. 

This type of support aims to improve someone’s life that is limited by illness through emotional, spiritual and physical support.  

A person receiving palliative care should be encouraged to choose a decision-maker for their health care and to note their preferences. 


What is to be included in the palliative care plan?

You will receive palliative care tailored to your individual needs, a person-centred care plan. 

 Care plan examples for the elderly are symptom management for palliative care. 

 Several steps are taken to improve your comfort and well-being as part of your palliative care plan. 

Here are a few of the instances which are included in the action plan: 

  • Prepare a list of symptoms you’re experiencing. Take notes on what causes your symptoms to improve or worsen and whether they affect how you live your life. 
  • Ensure you have a list of all of your medications and supplements with you. 
  • You may want to bring a friend or family member for the appointment. 
  • Care techniques to improve the existing well-being and nursing problems. 
  • Advance care planning of your desire (developing a will or an advance directive). 


The palliative care team will discuss your symptoms, treatment options, and how this illness affects you and your family.  

A palliative care team’s priority has a plan that prevents and eases pain and improves your daily life.  


Nursing care plan evaluation

There is no doubt that every patient receiving health care from Australian health care organisations is deserving of comprehensive care.  

A nursing care plan example includes the following:   

  • collaboration with the person receiving care 
  • to determine the level of involvement that they want to have in this process 

The nursing care plan is developed by complying with consumer-directed care. 

Apart from the patient, they can invite another person to help them prepare the plan (such as a carer or family member). 

Additionally, they may choose to deal with you through an advocate.  

One can refer to the Aged Care Assessment Test when discussing personal goals and needs.  

Once done with the care plan, one must submit it to the care receiver and home care agreement within 14 days.  


Risk for falls nursing care plan

The environment should be safe for all patients. No matter the identified risk, all patients should receive standard safety measures.  

The other step includes educating the family members.  

Whilst most family members are aware of maintaining a safe environment for their NDIS participants at home, most are unaware of the environmental risks.  

When in Short Term Accommodation (STA), or SDA, the participants, due to unfamiliarity with the environment, get accompanied by increased anxiety related to change in accommodation. 

So the community nursing care NDIS should make the participants and their families aware of the likeable possibilities beforehand.