Prioritizing The Nursing Problem List

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PrioritizingThe Nursing Problem List

• Using the Clinical Care Classification
• - an evidence based Nursing terminology
• in the patients plan of care

deborah.ariosto_at_vanderbilt.edu
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Objectives

• Describe components of the plan of care
• State the value of using evidence based care
  planning terms
• Understand the CCC Nursing terminology model
  within HED
• Develop Document a usable care plan using CCC
  problem (Dx) list

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VUMC Multi-DisciplinaryPlan of Care

• 1 Pathway Phase
• Sets timed objectives to meet discharge goals
  based on predominant medical or surgical plan
• 2 Provider Plan
• Orders planned procedures
• 3 Multi-Disciplinary Plans
• Reflects provider orders
• Contributes specialty focus
• 4 Reflects patient goals

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Pathway Phase

• Choose the pathway that most closely reflects the
  expected patient progression. Usually the reason
  for admission.
• Medical Pathway Heart Failure
• Admission Orders interventions are aimed at
  achieving stabilization ( improving pump action
  through diuresis, O2, hemodynamic stability, . .
  .)
• Stabilization - achieving a controlled symptoms
  (fluid excess control, med mgmt
• Discharge Ready for self-care or care by
  another caregiver.
• Surgical Pathway - Knee Replacement
• Pre-op Pre Post-op Stabilization Discharge

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• Managing/preventing problems can help reduce
  length of stay and improve the quality and cost
  bottom line
• Adverse patient effects
• hospital acquired conditions (infections,
  injuries)
• dissatisfaction (unhappy, lost wages) . . .
• Adverse VUMC effects
• lost revenue from under-reimbursed care days
• losing patients due to having no available beds .
  . .

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Plans of Care

• The clinical team implements the medical plan of
  care (orders)
• and
• contributes its own specialty focus by
• Assessment
• Diagnosis
• Plan
• Intervention
• Outcome evaluation

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Assessment

• Standards of Care (SOC)
• Physical Assessment (standard met/not met)
• Past medical/surgical/functional Assessment
• Baseline vital signs . . .
• Screening scales braden, fall, confusion, pain
• Population based SOC
• Scales Glascow coma, RASS, . . .
• More frequent and complex targeted assessment
• Mosbys evidenced based guidelines (diabetes )

SOC care administered without need for orders
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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.

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Evidence Base

• The 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
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CCC Frameworkfor the Nursing Plan of Care

• 21 Categories Skin Integrity
• 182 Problems (Dx)
• Oral Mucous Membranes Impairment
• 3 Expected Outcomes Improve, Stabilize, Support
  decline
• 198 Interventions Mouth Care
• 4 Actions Assess, Care, Teach, Manage
• 3 Actual Outcome Improved, Stabilized, Decline
  supported

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21 CCC Categories

• Physiological
• Cardiac
• Bowel/Gastric
• Life cycle (pregnancy)
• Metabolic (glucose)
• Physical Regulation (infection)
• Respiratory
• Skin Integrity
• Tissue Perfusion
• Urinary
• Medication

• Psych/Behavioral
• Cognitive
• Coping
• Health Behavior
• Role Relationship
• Self Care
• Self Concept
• Functional
• Activity
• Fluid Volume
• Nutrition
• Safety
• Sensory/Pain

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CCC Problem Coding59 major 123 sub-categories

• Category (R) Skin Integrity
• R46 Skin Integrity Alteration
• Change in or modification of skin conditions
• R46.1 Oral Mucous Membranes Impairment
• R46.2 Skin Integrity Impairment
• R46.3 Skin Integrity Impairment Risk
• R46.4 Skin Incision
• R46.5 Latex Allergy
• R47 Peripheral Alteration  
• Change in or modification of vascularization of
  the extremities

CCC codes map directly to multi-d concepts
(SNOMED) supported by NLM
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3 CCC OutcomesExpected/Actual

• 1. Improve/Improved
• Condition will change and/or recover (fracture,
  pneumonia)
• 2. Stabilize/Stabilized
• Underlying Condition will not change but requires
  no further nursing care to maintain (asthma,
  heart failure)
• 3. Support Decline/Decline Supported
• Condition will change and worsen (cancer, ESRD).
  Nursing action supports decline.

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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, IO, reduce anxiety.
• ____________________Initial Problem_______________
  _______________
• Priority Problem Fluid Volume Excess
• May be related to CHF, fluid intake, hi Na diet
• Exp Outcome Stabilize
• ______________________q shift plan and
  outcomes__________________
• Exp Outcome Detail diurese .5L this shift
• Exp Outcome Status Not Met
• Interventions chart as usual

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Activity Problems

•  Activity Alteration
• Change in or modification of energy used by the
  body
• Activity Intolerance
• Incapacity to carry out physiological or
  psychological daily activities
• Activity Intolerance Risk
• Increased chance of an incapacity to carry out
  physiological or psychological daily activities
• Activity Indifference
• Lack of interest or engagement in leisure
  activities
• Fatigue
• Exhaustion that interferes with physical and
  mental activities
• Mobility Impairment
• Diminished ability to perform independent
  movement
• Sleep Pattern Alteration
• Imbalance in the normal sleep/wake cycle
• Sleep Deprived
• Lack of the normal sleep / wake cycle
• MuscSkeletal Alt
• Change in or modification of the muscles, bones
  or support structures

Alt Alteration
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Physical Regulation

•  Physical Reg-Oth
• Change in or modification of somatic control
• Hyperreflexia
• Life threatening inhibited sympathetic response
  to a noxious stimuli in a person with a spinal
  cord injury at T7 or above
• Hyperthermia
• Abnormal high body temperature
• Hypothermia
• Abnormal low body temperature
• Thermoregulatory Impairment
• Fluctuation of temperature between hypothermia
  and hyperthermia
• Infection Risk
• Increased change of contamination with
  disease-producing germs
• Infection
• Contamination with disease-producing germs
• IntrCranialFluid
• Intracranial fluid volumes are compromised

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Prioritizing Problems

• Patients have many problems, what makes it a
  priority problem?
• When it
• Is the patients priority (pain, SOB, anxiety)
• Keeps the patient from moving to the next phase
  (fluid volume excess)
• High probability for harm (infection risk, falls)
• Delays discharge
• Note that Day Night shift may have different
  priorities (ambulation vs. sleep)

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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,
  IO, lo Na diet, fluid restriction) pick Fluid
  Volume Excess
• If you are focusing on breathing treatments,
  choose Respiratory Alteration
• -------Neither are wrong both may be selected
  -------

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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
  priorities
• Use the HED significance flag !
• Plan Priorities reflects priorities for the next
  12 hr.

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Plan of Care Report

• Available now in Standard HED format
• (many pages not well formatted)
• Use as Backup
• When paper is required
• i.e. Transfer to another facility
• August 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.

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Phase II - CCC Interventions

• Example
• Skin Integrity
• Wound Care
• Modifiers
• Assess wound care
• Perform wound care
• Teach wound care
• Manage wound care (consult)

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Future HED documentation will be mapped to the
action types

• RESPIRATORY CARE COMPONENT
• (1) Assess
• Breath Sounds
• RUL
• RLL
• LUL
• LLL
• SOB etc.
• (2) Perform
• Oxygen Therapy Care
• Breathing Exercises
• Chest PT
• Inhalation
• Ventilator Care
• Trach Care
• (3) Manage/Refer/Notify
• (4) Teach

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Phase III Reports Views

• 1. Printed Plan of Care to share with the patient
  and/or upload to MyHealth_at_V

• 2. Visualizing the problem list through
  Dashboards
• Staff Nurse View
• Unit Manager View
• Exec/Admin Views

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Graphical Display of Priority Problems
Problems key ? Priority ? Resolving ?
Resolved
Staff Nurse View cues to 1 CHF Monitor
cardiac, perfusion, fluid balance, resp 2
Diabetic Monitor glucose, diet, and skin 3
CABG Ambulate CABG protect from falls 4
Unknown Diarrhea, fever, hypercapneic
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Graphical Display of Priority Problems
Charge Nurse View Entire unit Possible C-Diff
outbreak
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Graphical Display of Priority Problems
Exec View Entire Hospital Highlights Discharge
Concerns Or Opportunities For targeted education
surveillance
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Spread the word

• Look for opportunities to use the CCC terms
  framework in your current work.

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Plan of Care Exercise

• Think about a recent patient and review their
  pathway
• Fracture
• Burn
• Asthma
• COPD
• Check of 3-5 high priority problems from the
  handout

• Refer to Mosbys evidence based plans of care if
  needed