Care Planning N251: 2012

1. Care PlanningN251: 2012

2. As RN’s, we use the nsg process to organize & deliver nursing care • It is used to identify, diagnose & treat human responses to health & illness • It provides a framework for nurses to think critically & make sound, reasonable decisions

3. The Nursing Process • 5 Components - assessment, nsg dx, planning, implementation, evaluation • Orderly & systematic approach to nsg practice • Cyclical & components interrelate • Client centered • Provides individual care • Use over the lifespan

4. Assessment

5. Assessment • Entails collection of complete data base • Must use organized format • Orem's Assessment Guidelines • Purpose – to enable planning and implementation of holistic individualized nursing care • Establishes a baseline

6. Assessment Data • Client – Primary Source (Subjective data) • Interview – communication skills important • Gain insight into clients feelings, worries, concerns • Determine chief complaint • Complete PQRST

7. P – provoking / aggravating factors • Q – quality & quantity • R – region / location - radiation / location • S – associated signs & symptoms/severity • T – time of onset, pattern, treatments tried & effects

8. Objective Data – data directly observed or measured • Main source – Physical Examination • Inspection, palpation, percussion, auscultation

9. Other Sources of Assessment Data • Lab / Diagnostic test results • Client’s medical record/chart • Other Health Care Professionals • Literature review • Nurse Intuition / practice experience

10. Documenting Assessment Data • Use Orem's Assessment form • Gather & cluster data under appropriate category • Record all assessed data • Record observations / facts only (raw data) • Be descriptive, concise, complete

11. Research Days • Gather as much assessment data as possible: • Conduct interview with client • Perform physical assessment • Review client’s chart and collect objective data from all available sources • Be organized – use your time well!

12. Begin to formulate possible nursing diagnoses based on your assessment findings • Be prepared to discuss your assessment findings and analysis of data with your clinical instructor • Remember – The extent of your data collection depends on the status of your client

13. Nursing Diagnostic Statements

14. After collecting data, the nurse organizes the information into meaningful clusters (groups of signs & symptoms) • While data clustering, the nurse organizes data & focuses on client functions that need support & assistance for recovery • The nsg diagnosis is a statement that describes the client’s actual or potential response to a health problem that the nurse is licensed & competent to treat

15. Nursing Diagnostic Statement • May contain three elements: • NURSING DIAGNOSIS • ETIOLOGY • DEFINING CHARACTERISTICS

16. May be one of three types: • Actual diagnosis • Risk for • Potential complication (collaborative problem)

17. 1. Nursing Diagnosis Actual Nursing Diagnosis: (Use your Carpenito text as a resource for this!) • Client is already experiencing this nursing problem (see Carpenito’s defining characteristics and criteria) • Contains three elements

18. Risk/High Risk for: • Client does not experiencethe problem currently but is at high risk of developing the problem • Contains two elements

19. PC (POTENTIAL COMPLICATIONS): (physiologic complications that nurses monitor to detect onset of changes in status) Risk for Complication (RC) • Require both physician prescribed and nursing prescribed interventions – hence, are collaborative problems • One part statement

20. 2. Etiology (contributing factors, influencing or risk factors) • These related factors have contributed to & influenced the change in the health status (4 categories: pathophysiologic, treatment related, situational, maturational) • All etiologies should be included • Be precise – may use ‘secondary to’ if helpful • Do not state medical diagnosis unless using as ‘secondary to’ in your etiology

21. Disturbed self-concept r/t multiple sclerosis – incorrect! • Disturbed self-concept r/t recent loss of role responsibilities 2° multiple sclerosis AEB “my mother comes every day to run my house” • Etiologies are included with actual or high risk problems but not for PC (potential complication) diagnostic statements

22. 3. DEFINING CHARACTERISTICS • These are the clinical criteria or assessment findings that support a nsg dx • Signs (objective data) • Symptoms (subjective data) • Other relevant data (ie. Lab data, test reports) • Designated as Major or Minor (see Carpenito) • Be specific – individualize • Included with actual problems only

23. Examples of Nursing Diagnostic Statements Actual diagnostic statements – 3 parts • Altered nutrition (less than body requirements ) r/t altered absorption of nutrients; decreased oral intake 2° Crohn’s disease amb 10% body weight loss and decreased serum albumin of 3.2 g/dl, decreased Hgb (8g/dl)

24. Impaired skin integrity r/t bowel incontinence, immobility, and obesity amb stage 2 decubitis ulcer on coccyx.

25. High Risk Nursing diagnostic statements – 2 part • High risk for altered nutrition (less than body requirements) r/t nutritional losses through diarrhea and vomiting 2° gastroenteritis

26. The validation to support an actual dx is signs & symptoms • Impaired skin integrity r/t immobility 2°to pain AEB 2cm erythematous sacral lesion • The validation to support a high risk diagnosis is risk factors • High risk for impaired skin integrity r/t immobility 2° pain

27. High risk for altered skin integrity r/t immobility and obesity. • High risk for infection r/t interrupted skin integrity from surgical incision 2°abdominal hysterectomy.

28. PC Diagnosis – one part statement Or RC • PC: Postpartum hemorrhage • PC: Atelectasis / Pneumonia • PC: Pulmonary Embolism

29. Recording DiagnosticStatements • Record diagnostic statements under the appropriate assessment category on Orem’s assessment sheet (ie. air, food, hazards, etc.) Note: not all category’s on Orem’s assessment form will have a nsg dx….only those that require it.

30. Realistically you can’t address ALL of the nsg dx. You will identify a priority set ( a group that takes precedence over the others) so the nurse can best direct resources toward goal achievement • Priority dx are those that if not managed now will deter progress to achieve outcomes or will negatively affect functional status • Non-priority are those for which treatment can be delayed without compromising present functional status

31. Summarize and prioritize complete list 1. most life threatening 2. those that interfere with normal functioning 3. those concerned with quality of life (Note: high risk nsg. diagnosis or a PC problem may also be a top priority depending on the degree of risk and severity of the problem)

32. Planning

33. Once you have assessed a client’s condition & identified appropriate nsg dx, a plan is developed for the client’s care • Planning involves establishing client goals & expected outcomes and selecting nsg interventions • Remember: plan of care is dynamic & will change as the client’s needs are met or as new needs are identified

34. Planning • Use Client’s Nursing Care Plan form • Use client’s Nursing Care Plan Guidelines • State diagnostic statement

35. Rationale for Nursing Diagnostic Statement • Explanation for the inclusion of Nursing Diagnostic Statement into this client’s plan of care • Two parts: literature based and client situation based

36. Literature based rationale: • Scientific research based and/or theoretical information from texts and journals

37. Cite sources of information using APA format • Define your diagnosis • Explain the relationship between the etiology and the diagnosis • Explain the appearance of the defining characteristics – why do they exist • Pathophysiology may be especially pertinent

38. Client Situation Rationale: • Explain the relationship between the client’s situational data and the nursing diagnostic statement

39. Provides data which will help to individualize/personalize the client’s nursing care plan • Include all sources of relevant data • Do NOT copy the same client situation rationale for all 3 care plans

40. Client Goals • Broad conceptual statements reflecting a desired health state or level of self-care for the client • Developed collaboratively • Must be observable & measurable, with a singular behavior • Client will communicate needs & adhere to treatment plan – incorrect – has 2 different behaviors

41. Client Outcomes • Client centered • Singular • Must be measurable (to extent possible) • Client specific (the degree of proficiency or conditions required for outcome to be achieved) • Realistic • Mutual • Time limited

42. An outcome is an objective criterion for measuring goal achievement • Client outcomes identify & measure the desired results of nursing interventions • Should have several outcomes for each goal

43. Sample: • Goal: client will achieve pain control • Client outcomes: • Client will report pain severity below 4 on a scale of 0 -10 • Client will report ability to sleep during the night without discomfort • The client will complete his bath without assistance by discharge

44. Sample: • Goal: client will have increased mobility • Client outcomes: • Client will demonstrate tolerance to activity as evidenced by a return to resting pulse (76 bpm) 3 min after activity • Client will remain OOB from 11am – 2pm and 5pm – 9pm within 48 hours post-op

45. After goals & outcomes for the nsg dx have been developed, the interventions in the plan of care are selected

46. Interventions • Client (when applicable) and Nurse Interventions • Partnership between client and nurse • Must be specific – individualized!! • Format – verb, noun, modifier • NOTE: Client interventions do not mirror nursing interventions

47. Rationale for Nursing Interventions • Describes/explains the basis for the interventions • Scientific research based and/or theoretical information from texts/journals • Additional rationale may emerge from client situational data

48. Rationale needs to be: • Current • Detailed and specific • Sources cited using APA format • Numbered to correspond with numbered interventions

49. Implementation

50. Implementation • Remember – client safety at all times!! • Must seek assistance when required • Accountable for own actions • Be aware of what you can and cannot do (as student nurses and own capabilities)