Care Plan/Concept Map Workshop

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Care Plan/Concept Map Workshop

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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.

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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

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The Nursing Process is a Systematic Five Step
Process

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

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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

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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.

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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.

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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

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5 Activities Needed to Perform a Systematic
Assessment

• Collect data
• Verify data
• Organize data
• Identify Patterns
• Report Record data

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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

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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

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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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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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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.

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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.

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Diagnostic Reasoning

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

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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

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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)

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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

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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.

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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

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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)

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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)

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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

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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

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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)

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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

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Implementation

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

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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

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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

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Implementation Process involves

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

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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

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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

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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

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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

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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

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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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