Transcript Risk for Impaired skin integrity related

Care Plan/Concept Map
Workshop
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.
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
The Nursing Process is a Systematic
Five Step Process
 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation
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
Putting 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 accurate
 Collect, verify, and organize data, identify
patterns, report and record the data.
 Report significant abnormalities immediately.
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 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.
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
5 Activities Needed to Perform a
Systematic Assessment
 Collect data
 Verify data
 Organize data
 Identify Patterns
 Report & Record data
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
What’s 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
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
Organizing 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 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
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.
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.
Diagnostic Reasoning
 Apply critical thinking to problem
identification
 Requires knowledge, skill, and
experience
 Big Picture
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
Nursing 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)
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
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.
Writing 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
diagnosis
 Refer to NANDA list in a nursing text
books
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)
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)
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
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
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)
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,
Implementation
 Putting your plan into action
 Set priorities after report
 Assess and reassess
 Perform interventions
 Chart client responses
 Give report to next shift
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
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
Implementation Process involves:
 Reassessing the client
 Reviewing and revising the existing care
plan
 Organizing resources and care delivery
(equipment, personnel, environment)
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
Evaluation
 Step of the nursing process that
measures the client’s response to
nursing actions and the client’s 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
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
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
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
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