Presentation on theme: "Prioritizing The Nursing Problem List"— Presentation transcript:
1 Prioritizing The Nursing Problem List Using the Clinical Care Classification- an evidence based Nursing terminologyin the patient’s plan of care
2 Objectives Describe components of the plan of care State the value of using evidence based care planning termsUnderstand the CCC Nursing terminology model within HEDDevelop & Document a usable care plan using CCC problem (Dx) list
3 VUMC Multi-Disciplinary Plan of Care 1 Pathway & PhaseSets timed objectives to meet discharge goals based on predominant medical or surgical plan2 Provider PlanOrders & planned procedures3 Multi-Disciplinary PlansReflects provider ordersContributes specialty focus4 Reflects patient goals
4 Pathway & PhaseChoose the pathway that most closely reflects the expected patient progression. Usually the reason for admission.Medical Pathway – Heart FailureAdmission – Orders & interventions are aimed at achieving stabilization ( improving pump action through diuresis, O2, hemodynamic stability, . . .)Stabilization - achieving a controlled symptoms (fluid excess control, med mgmtDischarge – Ready for self-care; or care by another caregiver.Surgical Pathway - Knee ReplacementPre-op Pre; Post-op Stabilization; Discharge
5 Managing/preventing problems can help reduce length of stay and improve the quality and cost bottom lineAdverse patient effectshospital acquired conditions (infections, injuries)dissatisfaction (unhappy, lost wages) . . .Adverse VUMC effectslost revenue from under-reimbursed care dayslosing patients due to having no available beds . . .
6 Plans of CareThe clinical team implements the medical plan of care (orders)andcontributes its own specialty focus byAssessmentDiagnosisPlanInterventionOutcome evaluation
7 Assessment Standards of Care (SOC*) Population based SOC Physical Assessment (standard met/not met)Past medical/surgical/functional AssessmentBaseline vital signs . . .Screening scales: braden, fall, confusion, painPopulation based SOCScales: Glascow coma, RASS, . . .More frequent and complex targeted assessmentMosby’s evidenced based guidelines (diabetes …)* SOC – care administered without need for orders
8 Nursing diagnoses = Problem List Nursing diagnosis is "a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable" (NANDA, 1992 p. 5). They describe clinical nursing practice in a uniform manner.
9 Evidence BaseThe 182 Clinical Care Classification* (CCC) problems (dx) were derived from 40,361 nursing diagnoses and/or patient problems collected from the research study patients for an entire episode of care as requiring nursing services including the actual outcome on discharge.Standardizing our clinical terms helps us share patient info across settings and disciplines; allows us to empirically test our interventions and build new evidence to advance the profession*Developed by Virginia K. Saba, RN , PhD
10 CCC Framework for the Nursing Plan of Care 21 Categories: Skin Integrity182 Problems (Dx):Oral Mucous Membranes Impairment3 Expected Outcomes: Improve, Stabilize, Support decline198 Interventions: Mouth Care4 Actions: Assess, Care, Teach, Manage3 Actual Outcome: Improved, Stabilized, Decline supported
12 CCC Problem Coding* 59 major & 123 sub-categories Category (R) Skin IntegrityR46 Skin Integrity AlterationChange in or modification of skin conditionsR46.1 Oral Mucous Membranes ImpairmentR46.2 Skin Integrity ImpairmentR46.3 Skin Integrity Impairment RiskR46.4 Skin IncisionR46.5 Latex AllergyR47 Peripheral Alteration Change in or modification of vascularization of the extremities*CCC codes map directly to multi-d concepts (SNOMED) supported by NLM
13 3 CCC Outcomes Expected/Actual 1. Improve/ImprovedCondition will change and/or recover (fracture, pneumonia)2. Stabilize/StabilizedUnderlying Condition will not change but requires no further nursing care to maintain (asthma, heart failure)3. Support Decline/Decline SupportedCondition will change and worsen (cancer, ESRD). Nursing action supports decline.
15 Plan of Care admission documentation ____________________Plan of Care Summary________________________Pathway: CHF (chart once) Phase: Admission (update prn)Nsg Summary: Pt admitted via ambulance in respiratory distress…Plan Priorities: IV diuretics, fluid restrictions, I&O, reduce anxiety….____________________Initial Problem______________________________Priority Problem: Fluid Volume ExcessMay be related to: CHF, fluid intake, hi Na dietExp Outcome: Stabilize______________________q shift plan and outcomes__________________Exp Outcome Detail: diurese .5L this shiftExp Outcome Status: Not MetInterventions: chart as usual
16 Activity Problems Alt = Alteration Activity Alteration Change in or modification of energy used by the bodyActivity IntoleranceIncapacity to carry out physiological or psychological daily activitiesActivity Intolerance RiskIncreased chance of an incapacity to carry out physiological or psychological daily activitiesActivity IndifferenceLack of interest or engagement in leisure activitiesFatigueExhaustion that interferes with physical and mental activitiesMobility ImpairmentDiminished ability to perform independent movementSleep Pattern AlterationImbalance in the normal sleep/wake cycleSleep DeprivedLack of the normal sleep / wake cycleMuscSkeletal AltChange in or modification of the muscles, bones or support structuresActivity ProblemsAlt = Alteration
17 Physical Regulation Physical Reg-Oth Hyperreflexia Hyperthermia Change in or modification of somatic controlHyperreflexiaLife threatening inhibited sympathetic response to a noxious stimuli in a person with a spinal cord injury at T7 or aboveHyperthermiaAbnormal high body temperatureHypothermiaAbnormal low body temperatureThermoregulatory ImpairmentFluctuation of temperature between hypothermia and hyperthermiaInfection RiskIncreased change of contamination with disease-producing germsInfectionContamination with disease-producing germsIntrCranialFluidIntracranial fluid volumes are compromisedPhysical Regulation
18 Prioritizing Problems Patients have many problems, what makes it a priority problem?When itIs the patient’s priority (pain, SOB, anxiety)Keeps the patient from moving to the next phase (fluid volume excess)High probability for harm (infection risk, falls)Delays dischargeNote that Day & Night shift may have different priorities (ambulation vs. sleep)
19 Choosing the best problem descriptor Choose the problem that most closely aligns with the interventions that you will do for this phase.My pt has Heart Failure – which problem do I pick?If you are focusing on fluid mgmt (IV diuretics, I&O, lo Na diet, fluid restriction) pick Fluid Volume ExcessIf you are focusing on breathing treatments, choose Respiratory AlterationNeither are wrong – both may be selected
20 Maintaining a short - usable Problem list Initiate problems thoughtfully & miserly – do not replicate standards of care unless they are a priority problem that you are actively monitoring or treating.Where possible, maintain the problems that have been started by the previous nurse until there has been significant progress towards goals or the problem has been resolved. Do not change for a slightly better descriptor.Not all problems need be addressed every shift – day and night shift will have different prioritiesUse the HED significance flag !Plan Priorities reflects priorities for the next 12 hr.
21 Plan of Care Report Available now in Standard HED format (many pages – not well formatted)Use as BackupWhen paper is requiredi.e. Transfer to another facilityAugust 2010:A 1-2 page plan of care summary will be available.Goal – create a paper plan of care that can be used in bedside report and given to the patient and family.
22 Phase II - CCC Interventions ExampleSkin IntegrityWound CareModifiers:Assess wound carePerform wound careTeach wound careManage wound care (consult)
23 Future: HED documentation will be mapped to the action types RESPIRATORY CARE COMPONENT(1) AssessBreath SoundsRULRLLLULLLLSOB etc.(2) PerformOxygen Therapy CareBreathing ExercisesChest PTInhalationVentilator CareTrach Care(3) Manage/Refer/Notify(4) Teach
24 Phase III – Reports & Views 1. Printed Plan of Care to share with the patient and/or upload to2. Visualizing the problem list through DashboardsStaff Nurse ViewUnit Manager ViewExec/Admin Views
28 Spread the wordLook for opportunities to use the CCC terms framework in your current work.
29 Plan of Care ExerciseThink about a recent patient and review their pathwayFractureBurnAsthmaCOPDCheck of 3-5 high priority problems from the handoutRefer to Mosby’s evidence based plans of care if needed