1. Chapter 4 The Planning Step: Creating the Plan of Care

2. The Planning Step Planning: Third step of the nursing process, during which goals/outcomes are determined and interventions chosen

3. The Planning Step  Plan of Care: Written evidence of the second and third steps of the nursing process that identifies the client’s needs, goals/outcomes of care, and interventions to treat the needs and achieve the outcomes

4. Setting Priorities for Patient Care  Starts with ranking the client’s needs  Maslow’s hierarchy of needs is a useful framework for this process

5. Maslow’s Hierarchy of Needs

6. Establishing Client Goals  Once you have prioritized client needs, establish the goals for treatment/discharge.  Goals (used broadly): Guidelines indicating the overall direction for movement as a result of the interventions of the healthcare team

7. Establishing Client Goals  Long-Term Goals: Those goals that may not be achieved before discharge from care but may require continued attention by the client and/or others  Short-Term Goals: Those goals that usually must be met before discharge or movement to a less acute level of care

8. Identifying Desired Outcomes(Goals) The next step is to determine specific outcomes—  Defined as client responses that are achievable and desired by the client  Can be attained within a defined period given the present situation and resources  Are the desired results of actions undertaken  Are measurable steps toward achieving the treatment/discharge criteria established earlier

9. Identifying Desired Outcomes Outcome statements need to:  Be specific  Be realistic  Consider the client’s circumstances and desires  Indicate a definite time frame  Provide measurable evaluation criteria for determining success or failure

10. Identifying Desired Outcomes  Desired outcomes are written by listing items/behaviors that can be observed and monitored to determine whether a positive/acceptable outcome has been achieved within the indicated time frame  This itemized listing of outcomes serves as the evaluation tool

11. Identifying Desired Outcomes  When outcomes are written properly, they provide direction for planning and validating the choice of appropriate nursing interventions  All outcomes should tell the reader specifically what the client is working on or doing

12. PLANNING  Clarifying expected outcomes/goals  Always start with “the patient…”  Measuring sticks for success of plan  Direct interventions  Provide time frame to motivate those involved  USE INDICATORS – THESE HELP MAKE OUTCOMES SPECIFIC!

13. PLANNING  Outcome statements:  Specific to patient!  Subject (ex. Patient)  Verb (measurable verb)  Condition (if necessary)  Criteria (ex. 50% of meal, for ½ hour, etc.)  Target time (by when!!!!)

14. PLANNING  The patient will report a reduction in frequency of stools to <3/day by 11/2/07.  Patient will exhibit balance of fluid volume by intake equal to output within 1 week.  Patient will demonstrate ability to transfer from bed to wheelchair without assistance in 3 days.

15. Selecting Appropriate Nursing Interventions  Nursing interventions: Any direct care treatment that a nurse performs on behalf of a patient, including nurse- and physician-initiated treatments, and provision of essential daily functions for the patient who cannot do them YOUR NURSING CARE

16. Selecting Appropriate Nursing Interventions  Nursing interventions are prescriptions for behaviors, treatments, activities, or actions that assist the client in achieving the expected outcomes

17. Selecting Appropriate Nursing Interventions Nursing interventions need to be based on:  The nursing diagnosis  The desired outcomes  The ability of the nurse to implement the intervention  The ability and willingness of the client to undergo the intervention  The appropriateness of the intervention

18. Selecting Appropriate Nursing Interventions Interventions must:  Be age-/situation-appropriate  Promote identified client strengths, when possible

19. Selecting Appropriate Nursing Interventions  Nurses are accountable for being current and accurate in identifying interventions  Nursing standards and agency policy must also be considered when choosing specific interventions

20. Sample Interventions (Nursing Orders)  Obtain weight each day before breakfast  Keep HOB elevated >30 degrees at all times  Refer patient to social service to ensure continued care.

21. Sample Interventions  Keep all necessary objects on patient’s right side.  Administer O2 @ 2L/min via NC to maintain pulse ox >93%  Instruct patient not to strain for bowel movement.

22. The Client Plan of Care The client plan of care is written to:  Provide continuity of care  Enhance communication  Assist with determining agency or unit staffing needs  Document the nursing process  Serve as a teaching tool  Coordinate care among disciplines

23. Discharge Planning  Begins when the client enters the healthcare setting  Nurse is responsible for planning continuity of care  between nursing personnel  between services within the care setting  between the care setting and the community

24. Documenting the Plan of Care  The format for documenting the plan of care is determined by agency policy  Whatever the format, the plan of care must reflect basic nursing standards of care  Personal client data, nonroutine care, and qualifiers such as time or amount are added as appropriate

25. Documenting the Plan of Care  Clinical pathways: A type of abbreviated plan of care providing outcome-based guidelines for goal achievement within a designated length of stay  Mind mapping: A care-planning technique using a graphic representation to visualize the interconnections among all the components of client care

26. Validating the Plan of Care Review the plan of care to ensure that:  It is based on accepted nursing practice  It provides for the safety of the client  Nursing diagnostic statements are supported by patient data

27. Validating the Plan of Care (cont.)  Review the plan of care to ensure that:  Goals and outcomes are measurable  The interventions can benefit the client and are logically sequenced  It demonstrates individualized client care

28. Chapter 5 The Implementation Step: Putting the Plan of Care into Action

29. The Implementation Step  Implementation: Fourth step of the nursing process, in which the plan of care is put into action; performing identified interventions/activities

30. Identifying Caregiving Priorities  No plan of care can predict everything that will happen with a client.  Your individual knowledge base, expertise, and recognition of agency routines allow you to adapt to the changing needs of the client/situation.

31. IMPLEMENTATION  Getting Report  Prep – look up info, read chart, arrive early, etc.  Use worksheets to organize info.  Taped reports can be reviewed as needed.

32. Setting Daily Priorities  Make initial rounds  Verify critical information  Identify urgent problems  Determine which problems to handle  Determine interventions  What can the patient do? What can be delegated?  Make (and follow) a worksheet

33. Assessing appropriateness of delegated interventions  Delegation does NOT change responsibility.  Appropriate tasks  Patient condition  Always remember your practice standards

34. Ethical and Legal Concerns  The wishes of the client and family/significant others about what is being done need to be discussed and respected.

35. Delivering Nursing Care  Interventions may be composed of many activities ranging from simple tasks to complex procedures.

36. Performing Interventions/ Reassessing  Always assess before and after interventions  Use each encounter as an opportunity  Preparation!  Know what you need to do  Know policies/procedures  Dealing with problems  KNOW THE RATIONALE BEHIND THE ACTION!

37. Ongoing Data Collection  Monitor the client to collect additional data.  This information will be used to make decisions about the need for new outcomes, and interventions and to re- prioritize the plan of care.

38. Documentation  It is legally required that all healthcare settings document nursing observations, the care provided, and the client’s response.  Many agencies use flow sheets to document routine activities, monitoring, and ongoing client care.

39. Charting  Assessment-Interventions-Responses  Purpose of charting:  Communicate care  Help identify patterns  Provide basis for evaluation (quality)  Create a legal document  Supply validation for insurance

40. Charting  Principles:  INITIAL and ongoing assessments  Interventions and nursing care performed  Patient RESPONSE  All charting should reflect nursing process.

41. Charting  Guidelines  Chart as soon as possible  Follow facility policy  Reflect  Record important action immediately  Record ALL variations from norm  Precise  Focus on significant events  Stick to facts  Sign

42. Verbal Communication with the Healthcare Team  The way information is conveyed can affect the way the information is heard and the quality of the healthcare provided.  Avoid judgmental language.  Be conscious of your tone of voice and body language.  Present information in an objective and accurate way.

43. Verbal Communication with the Healthcare Team Change of shift report includes:  Basic client data  Abnormalities/changes in assessment findings  Diagnostic procedures and results  Variations from usual routine  Activities not completed on your shift  Status of invasive treatments  Additions or changes to the plan of care

44. Verbal Communication with the Healthcare Team  Client confidentiality is an ethical/moral concern that must be respected by each professional at all times.  This requirement extends to conversations  at the nursing station  on the telephone  wherever client information is discussed

45. Chapter 6 The Evaluation Step: Determining Whether Desired Outcomes Have Been Met

46. The Evaluation Step Evaluation: Final step of the nursing process  An interactive process  Essential to ensuring quality care  Done by reviewing client responses

47. The Evaluation Step Focus is on:  Appropriateness of the care provided  Client’s progress (or) lack of progress toward desired goals

48. The Evaluation Step Three components:  Reassessment  Modification of the plan of care  Termination of services

49. Reassessment  An ongoing “measuring and monitoring” of the client’s status and response to nursing interventions

50. Reassessment Determines:  Appropriateness of nursing actions  Need to revise interventions  Development of new client needs  Required referrals  Need to rearrange priorities

51. Reassessment Outcomes/Goals may be evaluated by:  Direct observation  Client interview  Review of records

52. Reassessment When an outcome is not met completely, ask:  Were the outcomes realistic and appropriate?  Was the client involved in setting the outcomes?  Does the client believe the outcomes were important?  Does the client know why the outcomes have not been met?  Have all the identified interventions been carried out?  What variables may have affected achievement of the outcomes?  Were new needs/adverse client responses detected early enough to make appropriate changes?

53. Modification of the Plan of Care When the client’s condition has changed in an anticipated or unanticipated direction:  A change in treatment approach is indicated  The plan of care must be modified to reflect these changes

54. Modification of the Plan of Care  When revising outcomes, remember that they may simply need to be restated or have their time frames lengthened.

55. Modification of the Plan of Care Patient care conference—  Often “multi-disciplinary”  Chance to address the changing needs of the client/significant others  Opportunity to gain additional insights and problem-solve solutions

56. Termination of Services  Focus is on how the client will manage on his or her own  It is possible that not all goals/outcomes will be met before discharge

57. Termination of Services  Unmet goals/outcomes are reviewed and the reasons documented  The discharge plans are finalized and put into action

58. Termination of Services Discharge summary  Documents findings and client instructions/recommendations  Client is given a copy  May be shared with the home health nurse/primary healthcare provider

59. Enhancing Delivery of Quality Care  This is the key to:  Refining standards of care  Determining agency protocols, policies, and procedures  The provision of evidence-based nursing care

60. Chapter 7 Documenting the Nursing Process

61. Role of Documentation  A requirement for accreditation  A legal requirement  A record of the use of the nursing process for the delivery of individualized client care

62. Progress Notes Progress notes should:  Include all significant events  Be clear and objective  Reflect progress toward outcomes

63. Progress Notes 7 Functions  Staff documentation  Evaluation  Relationship monitoring  Reimbursement  Legal documentation  Accreditation  Training and supervision

64. Progress Notes Staff Communication  Colleague-to-colleague  Among nurses  Between the nursing staff and other healthcare providers

65. Progress Notes Evaluation For the purposes of review, the medical record should:  Be written to facilitate an assessment of the care provided  Serve as a method of tracking the client’s response to treatment  Be a means for evaluating the quality of care

66. Progress Notes Relationship Monitoring  Nurse/client relationship is a therapeutic relationship built on a series of interactions.  Notes detailing observations and monitoring of the client’s interactions are an important component of nursing care.

67. Progress Notes Reimbursement  The medical record provides proof of services.  Absence of such documentation may result in termination of funding or treatment.  Ex: MDS (Minimum Data Set) – required in long term care. Info must be reflected throughout notes.

68. Progress Notes Legal Documentation  All aspects of the medical record may be important for legal documentation  Notations need to be—  written in permanent ink/computer-entered  specific about date and time  signed by the person making the entry

69. Progress Notes Legal Documentation  An error must be—  crossed out with one line  still legible  identified as an “error”  initialed by the author  White-outs are not acceptable

70. Progress Notes (Legal Documentation)  If reported, record it!  Follow policies/procedures of your facility  Written: ink, legible, on-time, ONE LINE THROUGH MISTAKES! –  ….even better: GET IT RIGHT THE FIRST TIME.  Computer: Must know procedure for documentation (and correction of error!)  Chart objectively, quotes for subjective data.  Coherent, defensible

71. Guidelines: How to chart  Stick to the facts – see, hear, smell, feel, measure, and count.  Avoid labeling – objective description.  Be specific – avoid “adequate” or “good”  Use neutral language – nothing inappropriate!  Eliminate bias – avoid negative reference.  Keep record intact – never discard original, even if damaged. (Attempts to delete electronic records usually flagged)

72. RED FLAGS IN CHARTING  Improper corrections  Missing dates, times, or pages  Out of sequence  Additions added incorrectly  Additions in different handwriting/ink  Examples of spelling errors:  “Walk patient in hell”  Pt. appears to be seeping quietly”  Foley draining fowl-smelling urine”

73. Techniques for Descriptive Note Writing  Notes must give the reader a clear picture of what occurred with the client  To ensure clarity, use descriptive (or observational) statements  Avoid use of judgmental language

74. Judgmental Language  Statements of opinion  Open to varying interpretation  Lack supporting data

75. Judgmental Language Types of judgmental statements include phrases that:  Make reference to undefined time periods  Refer to undefined quantities  Refer to qualities  Fail to specify any objective basis for the judgment made

76. Descriptive Note Writing Undefined Periods of Time  Statements that refer to undefined periods of time without clarification may leave the statement unclear and judgmental. Watch for words such as:  often  rarely  seldom  almost always  frequently  occasionally  most of the time

77. Techniques for Descriptive Note Writing Undefined Quantities  Statements that refer to undefined quantities may be open to interpretation. Watch for words such as:  some  a lot  enough  many  a great deal  very little  too much

78. Techniques for Descriptive Note Writing Watch for words such as:  passive  nervous  Demanding  irritating  manipulative  alcoholic  incompetent  disturbed

79. Descriptive Note Writing Qualities  Observed behaviors may call for descriptions that are influenced by your own biases and cultural background.  Verify the connotations of such descriptions with others, especially the client, before using them.

80. Descriptive Note Writing Watch for words such as:  friendly  attentive  aloof  unhappy  excited  apathetic  enthusiastic  bored  proud

81. Descriptive Note Writing Qualities  Slang words are unclear and should not be contained in a professionally written note. Watch for words such as:  hyped-up  loose  spaced-out  pushy  cool  bummed  tanked-up  crazy

82. Descriptive Note Writing Objective Basis for Judgments  Recording your observations and giving an objective basis for your judgment reduces the possibility of miscommunication  The reader will not have to look elsewhere for clarification

83. Descriptive Note Writing  Avoid statements such as: “Michelle is improving.”  Instead, provide an objective basis for your judgment: “Michelle is improving; she walked the length of the hall using her crutches unassisted.”

84. Descriptive Note Writing Descriptive Language  Contains observations only  Avoids statements that are evaluative or judgmental  Contains measurable periods of time  Contains measurable quantities  Provides a basis or rationale for qualities named in the note

85. Descriptive Note Writing Content of Note/Entry  As specific and accurate as possible  Correct grammar and spelling  Legible writing  Abbreviations used cautiously or not at all

86. Descriptive Note Writing Content of Note/Entry  Concise, short, succinct sentences or phrases  Redundancy avoided  Consistent in style and format

87. Descriptive Note Writing Format of note entry may vary—  Block notes, with a single entry covering an entire shift  Narrative timed notes  Problem-oriented medical record system  Focus charting—viewing the client from a positive rather than a problem-oriented perspective

88. 1. The lab test indicated abnormal lover function. 2. The patient has no previous history of suicides. 3. Patient has left white blood cells at another hospital. 4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night. 5. Patient has chest pain if she lies on her left side for over a year. 6. On the second day the knee was better and on the third day it disappeared. 7. The patient is tearful and crying constantly. She also appears to be depressed. 8 The skin was moist and dry. 9. Discharge status: Alive but without permission. 10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful. ACTUAL NOTES (EXAMPLES)

89. 11. Patient had waffles for breakfast and anorexia for lunch. 12. She is numb from her toes down. 13. While in ER, she was examined, x-rated and sent home. 14. Occasional, constant infrequent headaches. 15. Patient was alert and unresponsive. 16. Examination of genitalia reveals that he is circus sized. 17. Skin: somewhat pale but present. 18. The pelvic exam will be done later on the floor. 19. Patient has two teenage children, but no other abnormalities.