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 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.

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 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.

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

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. 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

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

15. 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

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: client’s 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)
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

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 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

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