Care Plan/Concept Map Workshop

Nursing Care Plans/Concept Maps

Utilize the Nursing Process to construct an individualized plan of care for a patient based on a critical analysis of patient assessment data

Nursing Process: Systematic method of giving humanistic care that focuses on achieving outcomes in a cost effective manner.

Nursing Care Plans Written guidelines for client care Organized so nurse can quickly identify

nursing actions to be delivered Coordinates resources for care Enhances the continuity of care Organizes information for change of

shift report

The Nursing Process is a Systematic Five Step Process

Assessment Diagnosis Planning Implementation Evaluation

Why Use the Nursing Process for Care Plans

Requirement set forth by national practice standards (ANA, TJC)

Basis for NCLEX exams Based on principles and rules that

promote critical thinking in nursing

Putting it All Together Assessment: The first step in determining a

patients’s health status. Gather information, put pieces of the health

puzzle together. Entire plan is based on the data you collect,

data needs to be complete and accurate Collect, verify, and organize data, identify

patterns, report and record the data. Report significant abnormalities immediately.

Case Scenario Mr. Jones complains his throat and mouth

are dry. He is allowed fluids, but has had almost nothing to drink all evening. He tells you he would like to drink, but doesn’t like water, especially the warm water in the pitcher. He also hates to bother the nurse. The nurse notes his oral mucosa is dry and cracked and his urine output for the last shift is low.

Assessment First step in determining health status Gather information Gather all the “puzzle pieces” to put

together a clear picture of health status Entire plan is based on data collected Data needs to be complete and

accurate, make sense of patterns

5 Activities Needed to Perform a Systematic Assessment

Collect data Verify data Organize data Identify Patterns Report & Record data

Comprehensive Data Collection

Begins before you actually see the patient (Nurse report from ER, Chart reviews)

Continues with admission interview and physical assessment once you meet patient.

Other information resources include: family, significant others, nursing records, old medical records, diagnostic studies, relevant nursing literature.

Consider age, growth & development

What’s Important Data? Name, age, gender, admitting diagnosis Medical/surgical history, chronic illnesses Advanced Directives Laboratory Data/Diagnostic tests Medications Allergies Support Services Psychosocial/Cultural Assessment Emotional state Comprehensive Physical Assessment

Comprehensive Physical Assessment

Vital signs Height & weight Review of systems (neurological/mental

status, musculoskeletal, cardiovascular, respiratory, GI, GU, skin and wounds.

Standardized risk assessments: Pressure ulcers, falls, DVT

Organizing Assessment Data

Cluster data into groups according to a nursing or medical model (Maslow’s Basic Human Needs Model)

Clustering data helps maintain a nursing focus, allows patterns to be recognized

Cluster by body system or need deficit Helps to identify nursing diagnosis pertinent

to your client Example: All information gathered regarding

nutritional status may help to identify nutritional alterations

Diagnosis AssessmentCritical analysis of data

Diagnosis or Problem Identification Laws & standards continue to change to

reflect how nursing practice is growing (APN role)

Novice nurse responsible for recognizing health problems, anticipating complications, initiating actions to ensure appropriate and timely treatment.

Identifying Nursing Diagnosis

Common language for nurses A clinical judgment about an individual, family

or community response to an actual or potential health problem or life process,

Nursing diagnosis provide a basis for selection of nursing interventions so that goals and outcomes can be achieved

NANDA list of acceptable diagnoses, updated every 2 years.

Diagnostic Reasoning Apply critical thinking to problem

identification Requires knowledge, skill, and

experience Big Picture

Fundamental Principles of Diagnostic Reasoning

Recognize diagnoses Keep an open mind Back up diagnosis with evidence Intuition is a valuable tool for problem

identification Independent thinker Know your qualifications & limitations

Nursing Diagnosis Actual or Potential problems identified Actual: actual evidence of

signs/symptoms of diagnosis exist. (Fluid Volume Deficit)

Potential/Risk for Diagnosis: client’s data base contains risk factors of diagnosis, but no true evidence (Risk for altered skin integrity)

Writing a Nursing Diagnosis Actual Problems: Problem (NANDA

label) & Etiology & Supporting Signs and Symptoms

Impaired Communication related to language barrier as evidenced by inability to speak English

Writing a Nursing Diagnosis Potential or Risk Problems: Problem

(NANDA label) & etiology or problem & risk factors with related to statement linking problem to risk factors.

Risk for Impaired skin integrity related to obesity, excessive diaphoresis, and immobility.

Writing A Nursing Diagnosis

Use accepted qualifying terms (Altered, Decreased, Increased, Impaired)

Don’t use Medical Diagnosis (Altered Nutritional Status related to Cancer)

Don’t state 2 separate problems in one diagnosis

Refer to NANDA list in a nursing text books

Planning: 4 Part Process Set your priorities of care, what needs to be

done first, what can wait. Apply Nursing Standards, Nurse Practice Act,

National practice guidelines, hospital policy and procedure manuals.

Identify your goals & outcomes, derive them from nursing diagnosis/problem.

Determine interventions, based on goals. Record the plan (care plan/concept map)

Planning Risk for Impaired skin integrity related to

immobility Now restate the first clause in a statement

that describes improvement, control or absence of problem

The patient will have no signs of skin breakdown during hospital stay.

Outcome needs to be time related. ( state time period to achieve goal)

Short Term vs. Long Term Goals

Short term goal can be achieved in a reasonable amount of time ( few hours to few days)

Long term goals may take weeks/months to be achieved

Client will ambulate down the hall within 2 days.

Client will walk the length of the hallway independently by the end of 2 weeks

Achieving Goals/Outcomes Be realistic in setting goals. (look at overall

health state, growth & development level, prognosis)

Set goals mutually with client Goals should be measurable, use

measurable, observable verbs Identify one behavior per outcome When indicated use short-term vs. long tern

goals

Determining Interventions Nursing interventions are actions performed

by nurse to reach goal or outcome Monitor health status Minimize client risks Direct Care Intervention: Direct action

performed to client (inserting foley catheter) Indirect Care Intervention: actions performed

away from client ( looking at lab results)

Determining Interventions Interventions will be collaborative,

combining nursing actions and physician orders.

Ineffective Airway Clearance related to incisional pain

Nursing Actions: Ascultate breath sounds every four hours, Assist with coughing and deep breathing every hour etc.

Physician orders: pain medication, activity orders

Implementation Putting your plan into action Set priorities after report Assess and reassess Perform interventions Chart client responses Give report to next shift

Implementation of Nursing Interventions

Describes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completed

Action taken by nurse

Types of Nursing Interventions

Protocols: Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation

Standing Orders: Document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific condition

Implementation Process involves:

Reassessing the client

Reviewing and revising the existing care plan

Organizing resources and care delivery (equipment, personnel, environment)

Evaluation Evaluation of individual plan of care includes

determining outcome achievement Identify variables/factors affecting outcome

achievement Decide where to continue/modify/terminate plan Continue/modify/terminate plan based on

whether outcome has been met (partially or completely)

Ongoing assessment of QI

Evaluation

Step of the nursing process that measures the client’s response to nursing actions and the client’s progress toward achieving goals

Data collected on an on-going basis Supports the basis of the usefulness and

effectiveness of nursing practice Involves measurement of Quality of Care

Evaluation of Goal Achievement

Measures and Sources: Assessment skills and techniques

As goals are evaluated, adjustments of the care plan are made

If the goal was met, that part of the care plan is discontinued

Redefines priorities

Concept Map Care Plans Innovative approach to planning & organizing

nursing care. Essentially a diagram of patient problems and

interventions Ideas about patient problems and interventions

are the “concepts” to be diagrammed. Enhances critical thinking and clinical reasoning Used to organize patient data, analyze

relationships, establish priorities

Theoretical Basis of Concept Maps

Roots in education and psychology Also known as mind maps, cognitive

maps Concept mapping requires critical

thinking New knowledge is built on preexisting

knowledge, new concepts are integrated by identifying relationships

Steps in Concept Map Care Planning

Develop a Basic Skeleton Diagram Analyze and Catagorize Data Analyze Nursing Diagnoses

Relationships Identifying Goals, Outcomes, &

Interventions Evaluate patient responses