2Nursing 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 dataNursing Process: Systematic method of giving humanistic care that focuses on achieving outcomes in a cost effective manner.
3Nursing Care Plans Written guidelines for client care Organized so nurse can quickly identify nursing actions to be deliveredCoordinates resources for careEnhances the continuity of careOrganizes information for change of shift report
4The Nursing Process is a Systematic Five Step Process AssessmentDiagnosisPlanningImplementationEvaluation
5Why Use the Nursing Process for Care Plans Requirement set forth by national practice standards (ANA, TJC)Basis for NCLEX examsBased on principles and rules that promote critical thinking in nursing
6Putting 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 accurateCollect, verify, and organize data, identify patterns, report and record the data.Report significant abnormalities immediately.
7Case ScenarioMr. 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.
8Assessment First step in determining health status Gather information Gather all the “puzzle pieces” to put together a clear picture of health statusEntire plan is based on data collectedData needs to be complete and accurate, make sense of patterns
95 Activities Needed to Perform a Systematic Assessment Collect dataVerify dataOrganize dataIdentify PatternsReport & Record data
11Comprehensive 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
15Organizing 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 recognizedCluster by body system or need deficitHelps to identify nursing diagnosis pertinent to your clientExample: All information gathered regarding nutritional status may help to identify nutritional alterations
17DiagnosisAssessmentCritical analysis of data Diagnosis or Problem IdentificationLaws & 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.
18Identifying Nursing Diagnosis Common language for nursesA 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 achievedNANDA list of acceptable diagnoses, updated every 2 years.
19Diagnostic Reasoning Apply critical thinking to problem identification Requires knowledge, skill, and experienceBig Picture
20Fundamental Principles of Diagnostic Reasoning Recognize diagnosesKeep an open mindBack up diagnosis with evidenceIntuition is a valuable tool for problem identificationIndependent thinkerKnow your qualifications & limitations
21Nursing 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)
22Writing a Nursing Diagnosis Actual Problems: Problem (NANDA label) & Etiology & Supporting Signs and SymptomsImpaired Communication related to language barrier as evidenced by inability to speak English
23Writing 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.
24Writing 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 diagnosisRefer to NANDA list in a nursing text books
25Planning: 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)
26Planning Risk for Impaired skin integrity related to immobility Now restate the first clause in a statement that describes improvement, control or absence of problemThe patient will have no signs of skin breakdown during hospital stay.Outcome needs to be time related. ( state time period to achieve goal)
27Short 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 achievedClient will ambulate down the hall within 2 days.Client will walk the length of the hallway independently by the end of 2 weeks
28Achieving Goals/Outcomes Be realistic in setting goals. (look at overall health state, growth & development level, prognosis)Set goals mutually with clientGoals should be measurable, use measurable, observable verbsIdentify one behavior per outcomeWhen indicated use short-term vs. long tern goals
29Determining Interventions Nursing interventions are actions performed by nurse to reach goal or outcomeMonitor health statusMinimize client risksDirect Care Intervention: Direct action performed to client (inserting foley catheter)Indirect Care Intervention: actions performed away from client ( looking at lab results)
30Determining Interventions Interventions will be collaborative, combining nursing actions and physician orders.Ineffective Airway Clearance related to incisional painNursing Actions: Ascultate breath sounds every four hours, Assist with coughing and deep breathing every hour etc.Physician orders: pain medication, activity orders
31Implementation Putting your plan into action Set priorities after reportAssess and reassessPerform interventionsChart client responsesGive report to next shift
32Implementation of Nursing Interventions Describes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completedAction taken by nurse
33Types of Nursing Interventions Protocols: Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situationStanding Orders: Document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific condition
34Implementation Process involves: Reassessing the clientReviewing and revising the existing care planOrganizing resources and care delivery (equipment, personnel, environment)
35EvaluationEvaluation of individual plan of care includes determining outcome achievementIdentify variables/factors affecting outcome achievementDecide where to continue/modify/terminate planContinue/modify/terminate plan based on whether outcome has been met (partially or completely)Ongoing assessment of QI
36EvaluationStep of the nursing process that measures the client’s response to nursing actions and the client’s progress toward achieving goalsData collected on an on-going basisSupports the basis of the usefulness and effectiveness of nursing practiceInvolves measurement of Quality of Care
37Evaluation of Goal Achievement Measures and Sources: Assessment skills and techniquesAs goals are evaluated, adjustments of the care plan are madeIf the goal was met, that part of the care plan is discontinuedRedefines priorities
38Concept Map Care PlansInnovative approach to planning & organizing nursing care.Essentially a diagram of patient problems and interventionsIdeas about patient problems and interventions are the “concepts” to be diagrammed.Enhances critical thinking and clinical reasoningUsed to organize patient data, analyze relationships, establish priorities
39Theoretical Basis of Concept Maps Roots in education and psychologyAlso known as mind maps, cognitive mapsConcept mapping requires critical thinkingNew knowledge is built on preexisting knowledge, new concepts are integrated by identifying relationships
40Steps in Concept Map Care Planning Develop a Basic Skeleton DiagramAnalyze and Catagorize DataAnalyze Nursing Diagnoses RelationshipsIdentifying Goals, Outcomes, & InterventionsEvaluate patient responses