Care Planning

As RNs, we use the nsg process to organize & deliver nursing careIt is used to identify, diagnose & treat human responses to health & illnessIt provides a framework for nurses to think critically & make sound, reasonable decisions

The Nursing Process5 Components - assessment, nsg dx, planning, implementation, evaluationOrderly & systematic approach to nsg practiceCyclical & components interrelateClient centeredProvides individual careUse over the lifespan

Assessment

AssessmentEntails collection of complete data baseMust use organized formatOrem's Assessment GuidelinesPurpose to enable planning and implementation of holistic individualized nursing careEstablishes a baseline

Assessment DataClient Primary Source (Subjective data)Interview communication skills importantGain insight into clients feelings, worries, concernsDetermine chief complaint Complete PQRST

P provoking / aggravating factorsQ quality & quantityR region / location - radiation / locationS associated signs & symptoms/severityT time of onset, pattern, treatments tried & effects

Objective Data data directly observed or measured

Main source Physical ExaminationInspection, palpation, percussion, auscultation

Other Sources of Assessment DataLab / Diagnostic test resultsClients medical record/chartOther Health Care ProfessionalsLiterature reviewNurse Intuition / practice experience

Documenting Assessment DataUse Orem's Assessment formGather & cluster data under appropriate categoryRecord all assessed dataRecord observations / facts only (raw data)Be descriptive, concise, complete

Research DaysGather as much assessment data as possible:Conduct interview with clientPerform physical assessmentReview clients chart and collect objective data from all available sourcesBe organized use your time well!

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

Nursing Diagnostic Statements

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 recoveryThe nsg diagnosis is a statement that describes the clients actual or potential response to a health problem that the nurse is licensed & competent to treat

Nursing Diagnostic StatementMay contain three elements:

NURSING DIAGNOSISETIOLOGYDEFINING CHARACTERISTICS

May be one of three types:

Actual diagnosis

Risk for

Potential complication (collaborative problem)

1. Nursing DiagnosisActual Nursing Diagnosis: (Use your Carpenito text as a resource for this!)

Client is already experiencing this nursing problem (see Carpenitos defining characteristics and criteria)

Contains three elements

Risk/High Risk for:

Client does not experience the problem currently but is at high risk of developing the problem

Contains two elements

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 problemsOne part statement

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 includedBe precise may use secondary to if helpfulDo not state medical diagnosis unless using as secondary to in your etiology

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 houseEtiologies are included with actual or high risk problems but not for PC (potential complication) diagnostic statements

3. DEFINING CHARACTERISTICS

These are the clinical criteria or assessment findings that support a nsg dxSigns (objective data)Symptoms (subjective data)Other relevant data (ie. Lab data, test reports)Designated as Major or Minor (see Carpenito)Be specific individualizeIncluded with actual problems only

Examples of Nursing Diagnostic StatementsActual diagnostic statements 3 parts

Altered nutrition (less than body requirements ) r/t altered absorption of nutrients; decreased oral intake 2 Crohns disease amb 10% body weight loss and decreased serum albumin of 3.2 g/dl, decreased Hgb (8g/dl)

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

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

The validation to support an actual dx is signs & symptoms Impaired skin integrity r/t immobility 2to pain AEB 2cm erythematous sacral lesionThe validation to support a high risk diagnosis is risk factorsHigh risk for impaired skin integrity r/t immobility 2 pain

High risk for altered skin integrity r/t immobility and obesity.

High risk for infection r/t interrupted skin integrity from surgical incision 2abdominal hysterectomy.

PC Diagnosis one part statementOr RCPC: Postpartum hemorrhage

PC: Atelectasis / Pneumonia

PC: Pulmonary Embolism

Recording Diagnostic Statements

Record diagnostic statements under the appropriate assessment category on Orems assessment sheet (ie. air, food, hazards, etc.)

Note: not all categorys on Orems assessment form will have a nsg dx.only those that require it.

Realistically you cant 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 statusNon-priority are those for which treatment can be delayed without compromising present functional status

Summarize and prioritize complete list1. most life threatening2. those that interfere with normal functioning3. 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)

Planning

Once you have assessed a clients condition & identified appropriate nsg dx, a plan is developed for the clients carePlanning involves establishing client goals & expected outcomes and selecting nsg interventionsRemember: plan of care is dynamic & will change as the clients needs are met or as new needs are identified

PlanningUse Clients Nursing Care Plan form

Use clients Nursing Care Plan Guidelines

State diagnostic statement

Rationale for Nursing Diagnostic StatementExplanation for the inclusion of Nursing Diagnostic Statement into this clients plan of care

Two parts: literature based and client situation based

Literature based rationale:

Scientific research based and/or theoretical information from texts and journals

Cite sources of information using APA formatDefine your diagnosisExplain the relationship between the etiology and the diagnosisExplain the appearance of the defining characteristics why do they existPathophysiology may be especially pertinent

Client Situation Rationale:

Explain the relationship between the clients situational data and the nursing diagnostic statement

Provides data which will help to individualize/personalize the clients nursing care plan

Include all sources of relevant data

Do NOT copy the same client situation rationale for all 3 care plans

Client GoalsBroad conceptual statements reflecting a desired health state or level of self-care for the clientDeveloped collaborativelyMust be observable & measurable, with a singular behaviorClient will communicate needs & adhere to treatment plan incorrect has 2 different behaviors

Client OutcomesClient centeredSingularMust be measurable (to extent possible)Client specific (the degree of proficiency or conditions required for outcome to be achieved) RealisticMutualTime limited

An outcome is an objective criterion for measuring goal achievementClient outcomes identify & measure the desired results of nursing interventionsShould have several outcomes for each goal

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

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

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

InterventionsClient (when applicable) and Nurse InterventionsPartnership between client and nurseMust be specific individualized!!Format verb, noun, modifierNOTE: Client interventions do not mirror nursing interventions

Rationale for Nursing InterventionsDescribes/explains the basis for the interventionsScientific research based and/or theoretical information from texts/journalsAdditional rationale may emerge from client situational data

Rationale needs to be:CurrentDetailed and specificSources cited using APA formatNumbered to correspond with numbered interventions

Implementation

ImplementationRemember client safety at all times!!Must seek assistance when requiredAccountable for own actionsBe aware of what you can and cannot do (as student nurses and own capabilities)

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ImplementationMust be prepared for clinical practice lab skills, appropriate researchWork on time management and organizational skillsTime schedule

Evaluation

EvaluationEvaluation of client goals and client outcomes - were they met, partially met, or unmet, why

Evaluation of interventions- What interventions were helpful/not helpful, why, what changes must be made in plan of care, etc.

Major Nursing Care Plan

Written Client Nursing Care PlansDocument the nursing processLearning/evaluation toolEnhances critical thinkingDemonstrates students knowledge and preparation for nursing practice

Major Nursing Care Plan AssignmentComprehensive assessment (Orems Assessment form)

Complete Physical Assessment

3 completed Clients Nursing Care Plans (three top priority diagnosis)

Reference list

Major Care Plan AssignmentNormally (3rd and 4th yr) one journal article required as a reference for each of the three care plans.

A minimum of one article in any of the three plans is acceptable. (use your N251 bib list)Attach the article to your care plan

Major Care Plan Assignment1 major care plan assignments required in N 252

Due Date TBA

Value of overall assignment will be reduced for late assignments

Graded PASS /FAIL

Daily expectations r/t client nursing care plans and practice

Updated daily to reflect changes in clients status and changes in required nursing careReviewed by instructors constructive feedback given

Collecting Data on Research DayChoose a quiet, private, well-lit setting makes it easier for you & your client to interact Make sure the client is comfortableIntroduce yourself, explain the purpose of why you are gathering a health history & assessment to identify the patients problem & gather information so that you can plan his care

Reassure them that everything he/she says will be kept confidential

CommunicationAssess the patient to see if language barriers exist or if he/she can hear youSpeak slowly & clearly, avoid medical jargonAddress the patient by a formal name (ie. Mrs. Jones). Dont call them by their first name unless they give you permission to do soListen attentively, make eye contact

Make reassuring gestures, such as nodding your head, to encourage the patient to keep talkingWatch for nonverbal cues indicating that they are uncomfortableBe aware of your own nonverbal behaviors that may cause the patient to shut down or become defensive.

RE-ASSESSING THE HOSPITALIZED CLIENT

A hospitalized client does not require a complete head to toe physical assessment every shiftEvery client does require a focused assessment every shift, at the start of the shiftSome measures are daily daily weights, calf circumference Some assessments may need to be done frequently throughout the shift depending on client status

Applies to adults in medical, surgical, and cardiac set-down unitsComplete a 5 minute screening assessment at the beginning of your shiftBegin by introducing yourself as their nurse for the next 8 hours, make eye contact, & ask them how they are feeling, how they spent the previous shift, & if they are having any pain/discomfort

General AppearanceFacial expression appropriate to situation?Body position relaxed? Level of consciousness? Alert, oriented, & responding to your questions?Speech clear & understandable?Hearing? Are their responses consistent with having heard what you said?Personal hygiene? Attending to hair, make-up, shave?

MeasurementsTemperaturePulseRespirationsBlood pressurePulse oximetry Rate their pain on scale 1 10If pain meds given, note response

NeurologicalEyes open spontaneously to name?Motor response? Verbal response?Pupil size & response?Muscle strength, R & L, upper & lower?Any ptosis, facial droop?Sensation?

Respiratory If oxygen by mask, nasal prongs, check fittingRespiratory effort?Auscultate breath sounds, posterior & anteriorCough & deep breathe, any mucus? Note color & amount

Cardiovascular Auscultate rhythm at apex, regular/irregular?Check apical pulse against radial pulse, note perfusion of beatsAssess heart sounds in all locations, diaphragm & bellCheck cap refillCheck pretibial edemaPalpate posterior tibial & dorsalis pedis pulses, R & LVerify proper IV solution is hanging & flowing at proper rate

Skin Note color, temperatureNote elasticityAny lesionsIf dressings in place, note their condition

Abdomen Assess contourListen to bowels sounds

Genitourinary Inquire whether voiding regularlyCheck urine for color, clarity

Activity Note any assistance needed with sitting up, moving to chair, ambulating

A complete head to toe assessment is required for your major care plan assignment

*5 components Assessment - Nursing diagnosis planning implementation, - evaluation