1. Prioritizing The Nursing Problem List
Using the Clinical Care Classification
- an evidence based Nursing terminology
in the patient’s plan of care

2. 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

3. VUMC Multi-Disciplinary Plan 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

4. 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

5. 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 . . .

6. 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

7. Assessment Standards of Care (SOC*) Population based 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
Mosby’s evidenced based guidelines (diabetes …)
* SOC – care administered without need for orders

8. 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.

9. 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

10. CCC Framework for 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

11. 21 CCC Categories Physiological Psych/Behavioral Functional 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

12. CCC Problem Coding* 59 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

13. 3 CCC Outcomes Expected/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.

15. 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, I&O, 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

16. Activity Problems Alt = Alteration 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
Activity Problems
Alt = Alteration

17. Physical Regulation Physical Reg-Oth Hyperreflexia Hyperthermia
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
Physical Regulation

18. Prioritizing Problems
Patients have many problems, what makes it a priority problem?
When it
Is the patient’s 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)

19. 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, I&O, 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

20. 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.

21. 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.

22. Phase II - CCC Interventions
Example
Skin Integrity
Wound Care
Modifiers:
Assess wound care
Perform wound care
Teach wound care
Manage wound care (consult)

23. 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

24. Phase III – Reports & Views
1. Printed Plan of Care to share with the patient and/or upload to
2. Visualizing the problem list through Dashboards
Staff Nurse View
Unit Manager View
Exec/Admin Views

25. 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

26. Graphical Display of Priority Problems
Charge Nurse View
Entire unit
Possible C-Diff outbreak

27. Graphical Display of Priority Problems
Exec View
Entire Hospital
Highlights Discharge Concerns Or
Opportunities
For targeted education & surveillance

28. Spread the word
Look for opportunities to use the CCC terms framework in your current work.

29. 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 Mosby’s evidence based plans of care if needed