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Care Plan/Concept Map Workshop

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Care Plan/Concept Map Workshop Implementation Process involves: Reassessing the client Reviewing and revising the existing care plan Organizing resources and care ... – PowerPoint PPT presentation

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Title: Care Plan/Concept Map Workshop


1
Care Plan/Concept Map Workshop

2
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.

3
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

4
The Nursing Process is a Systematic Five Step
Process
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

5
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

6
Putting it All Together
  • Assessment The first step in determining a
    patientss 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.

7
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 doesnt 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.

8
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

9
5 Activities Needed to Perform a Systematic
Assessment
  • Collect data
  • Verify data
  • Organize data
  • Identify Patterns
  • Report Record data

10
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11
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

12
Whats 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

13
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

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15
Organizing Assessment Data
  • Cluster data into groups according to a nursing
    or medical model (Maslows 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

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17
Diagnosis
  • Assessment?Critical 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.

18
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.

19
Diagnostic Reasoning
  • Apply critical thinking to problem identification
  • Requires knowledge, skill, and experience
  • Big Picture

20
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

21
Nursing Diagnosis
  • Actual or Potential problems identified
  • Actual actual evidence of signs/symptoms of
    diagnosis exist. (Fluid Volume Deficit)
  • Potential/Risk for Diagnosis clients data base
    contains risk factors of diagnosis, but no true
    evidence (Risk for altered skin integrity)

22
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

23
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.

24
Writing A Nursing Diagnosis
  • Use accepted qualifying terms (Altered,
    Decreased, Increased, Impaired)
  • Dont use Medical Diagnosis (Altered Nutritional
    Status related to Cancer)
  • Dont state 2 separate problems in one diagnosis
  • Refer to NANDA list in a nursing text books

25
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)

26
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)

27
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

28
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

29
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)

30
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

31
Implementation
  • Putting your plan into action
  • Set priorities after report
  • Assess and reassess
  • Perform interventions
  • Chart client responses
  • Give report to next shift

32
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

33
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

34
Implementation Process involves
  • Reassessing the client
  • Reviewing and revising the existing care plan
  • Organizing resources and care delivery
    (equipment, personnel, environment)

35
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

36
Evaluation
  • Step of the nursing process that measures the
    clients response to nursing actions and the
    clients 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

37
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

38
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

39
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

40
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

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