implementing the nursing care plan

Administration of Nursing Service

CARLEA C. SANA(Reporter)

Implementation of Nursing Care

Plan

Is the step during which the nurse performs activities necessary for the achievement of the client’s health goals.

To implement the nursing care plan effectively, the nurse must have the knowledge, skills, and attitudes to carry them out.

Implementation of Nursing Care Plan

Nurse reviews nursing care plan then compares it with the assessment data to validate the nursing diagnosis and to determine weather the nursing interventions stated are the most appropriate to meet the patient’s problems and needs.

Validation is made with other nurses who are more knowledgeable and experienced. Another member of heath team such as nutritionist may be consulted when patient needs special diet..

Nursing care plan may also be validated with the patient, his/her family and/or significant others.

Validating nursing care plan

nurse should consider the following areas and guidelines:

1. Individualized nursing care Considers the patient’s preferences,

physical and psycho-social need.2. Safety

Proper precaution should be observed to prevent any accident or injury to patient.

3. Appropriateness Plan should be congruent to the medical

plan and treatment with standard protocols and procedures for particular health setting.

4. Effectiveness Nursing actions should realistically help

patient achieve the intended outcomes.

Validating nursing care plan

Preparation of the Nurse to do the job Nurse should review nursing action to be

done and the rationale for doing so. Nurse determines weather any change in

the patients condition warrants modification in nursing intervention.

Nurse should clarify any doubts with the Head Nurse. If the doubt pertains to a medical order, verification should be made with the ordering physician.

Preparing for nursing activities

Preparing the client Patient should be fully informed about

the purpose of the nursing action, its rationale, what he/she can expect from it and what is expected from him/her.

Assess the patient's readiness for the procedure to be done.

Provide assistance and privacy to prevent unnecessary stress or discomfort.


Preparing the Equipment and SuppliesMuch time can be saved and

nursing actions can be done efficiently when all equipment and supplies are prepared at hand prior to the start of the nursing intervention.


Nurse applies her knowledge, skills, and interpersonal relationships in performing or delegating planned nursing strategies. She utilizes independent, dependent, and interdependent nursing actions.

Implementing the nursing intervention

Independent/ autonomous nursing intervention Consultation with physicians or another

health professionals is not necessary in performing these nursing interventions.(e.g. health promotion etc.)

Assistance in Activities of daily living Nurse provides health teachings to

motivate patient and family. Counseling

Needed to help patient manage his/her stresses as a result of actual or impending changes brought about by illness.


Dependent nursing intervention Based on instructions or written orders

of physicians for treatment, therapies, and medications.

Nurse should ensure that he/she understands the order correctly. He/she should know a medication’s action, possible reactions, dosage, route and patient for whom it is intended.

Proper documentation should be made in patients chart.


Interdependent nursing intervention Are those that are carried out in

collaboration with other health team members such as the physical therapist, nutritionist, and physician.

Reflects overlapping of responsibilities and relationships between health personnel.


It is a formal legal document that provides evidence of how the patient’s care was managed.

The process of making an entry to the record is called charting, recording, or documenting.* Patients record are treated as

confidential.* According to the Code of Ethics for

Filipino Nurses, “Only those who are professionally and directly involved in patient’s care and when requested by law” may see the patients chart.

The patient’s clinical record

Purposes of Documentation:1. Communication

Facilitates continuity of care, prevents duplication of efforts, and prevents misunderstanding.

2. Planning Patient Care Data from patient’s chart may be used by

each member of health team.

3. Research The information documented in the

patient’s chart is a valuable source for those investigating cases with the same condition or are given same treatment.


Purposes of Documentation:4. Education

Patient’s record becomes a valuable tool for health care professionals as they provide comprehensive information on the client, his illness, and the factors that positively or negatively affect his care.

5. Audit A review of patient’s chart shows weather

the health agency complies with the standards set for patient care.

6. Reimbursement of Health Insurance Patient’s chart helps health agency in

receiving reimbursements or PhilHealth etc.


Purposes of Documentation:7. Legal

Patient’s record is considered a legal document and is admissible in court evidence.

8. Health Care Analysis Records are utilized to identify the

agency’s needs in both human and material resources, cost analysis of the resources utilized and service rendered..


The quality of care received by patients, the standards of nursing practice, the reimbursement structure in the healthcare system and the legal guidelines for the practice of nursing make reporting and documentation two of the most important functions of the nurse.

Reporting and documenting

GUIDELINES FOR GOOD REPORTING AND DOCUMENTATION:

1. Factual Information about the patients and

their care must be based on facts that are descriptive and objective, not on opinions.

2. Accurate Client’s record must be accurate and

reliable. Measurements should be accurate.

Reporting and documenting


3. Confidential Code of Ethics for Filipino Nurses,

“Only those who are professionally and directly involved in patient’s care and when requested by law” may see the patients chart.

4. Complete Charting should be complete and

concise giving only essential information. Unnecessary and lengthy words or irrelevant details should be avoided.


5. Current Recording and reporting should be up-

to-date.6. Organized

Information should be communicated in a logical format or sequence. Disorganized data may lead to confusion and errors.

7. Ethical Negative or retaliatory remarks about a

patient or a member of health team should be avoided as these breed ill-feeling and poor relationships.

Precautions to Observe in Documentation1. Only the nurse who performs the nursing

intervention makes the entry and sign it.2. Charting made by nursing students should

be countersigned by their clinical instructor.

3. Chart all important information before leaving the unit. Another nurse may possibly duplicate the giving of medications if not documented properly.

4. Do not make erasures. Draw a line through the error and write the word “mistaken entry” above it. Sign name or initials and make the correct entry after it.

Are Either oral, taped, or written exchanges of information between nurses and/or members of the health team. These include change-of-shift reports, telephone orders and reports, and transfer reports.

Change-of-Shift Reports Is a system of communication aimed at

transferring essential information and holistic care for patients. Its purpose is to provide continuity of patient care for 24 hrs.

May be given orally, by audio-tape recording, or at the bedside during nursing rounds.

Reports

Change-of-Shift Reportsa. Oral Report

Prior to the nursing rounds, a pre conference is made at the nurses station or conference room.

b. Audio-tape Report Made by outgoing nurse and is replayed

by incoming nurse.c. Nursing Rounds

Are made at the patient’s bedside. Patient’s care plan is discussed. This enables the patient and his family to participate in discussion.

Telephone Reports and Orders Information given through telephone should

accurately transcribed by the receiving nurse in written form especially if this pertains to medications or significant changes/events in clients condition occurred.

Legal Risk in Telephone Orders* May be misunderstood or misinterpreted by

receiving nurse. May sound unclear because of some trouble in telephone line.

* Signature of ordering physician is not present and this order may be denied in case errors exist or when court litigations arise.

Telephone Reports and OrdersOnly in an extreme emergency and when no other resident or medical intern is available should a nurse receive telephone order. Nurse should read back such order to the

physician. Such order should be signed by physician as

soon as he arrive at the hospital. Nurse should note the date and time the order

was made, name of physician making order, then sign own name including designation.

Example: 2-25-14 - discontinue Iv infusion when consumed

3:20 PMTel. Order Dr. J.V.Santos/

P.F Roxas BSN,RNStaff Nurse

Transfer Reports Contains information that the nurse in the

receiving unit needs to know for continuity of care. This includes summary of the medical progress up to the time of transfer (usually made by physician), current health status, critical assessment or interventions to be completed after transfer and special equipment necessary.

Before patient is transferred to another agency, proper coordination must be first made to ensure that the agency has the proper services and facilities needed by the patient.

Nurse and a transfer report accompanies patient.

Patients medical record (chart) left at original agency.

Is anything printed or written that can be used as a record or proof for authorization.

Standards of Nursing Practice state that documentation of nursing care should b pertinent and concise and should reflect patient’s status.

Nursing documentation shall address the patients needs, problems, capabilities and limitations. Nursing interventions provided and patients responses should be noted.

documentation

Forms for Nursing DocumentationForms vary according to the institution’s needs. They are used to make documentation easy, quick, and comprehensive. They present special types of information that eliminates repeated date in the nursing notes.Nursing Health History and Assessment Worksheet This is a special form completed by the nurse

when patient is admitted to the unit. It contains basic biographical data, present

illness, health history, physical assessment, including nursing diagnosis on admission.

Forms for Nursing DocumentationGraphic Flow SheetForms that allow nurses to record

specific measurements or observations on a repeated basis.

Examples are graphic flow sheet that record routine measurements at specific intervals such as vital signs.

Medicine and Treatment Record Contains all medication and treatments

given on a repeated basis.

Forms for Nursing DocumentationNursing Kardex Trademark for a card-filing system that

allows quick reference to the particular needs of each patient for certain aspects of nursing care. Included on the card may be a schedule of medications, level of activity allowed, ability to perform basic self-care, diet, any special problems, a schedule of treatments and procedures, and a care plan.

Is updated as necessary and is usually kept at the nurses' station.

Forms for Nursing DocumentationDischarge Summary Is a special progress report that helps ensure

that a client’s discharge results in a desirable outcomes.

The discharge planning and summary concise and instructive. This includes the ff data:

1. Teaching and counseling to prepare the patient for discharge;

2. Current medications & treatments to be continued and precautions to observe and report;

3. Activities of daily living and self-care activities

4. Support system5. Person who will accompany patient on

discharge; and6. Destination weather at home or transferred to

other agency/hospital.

Forms for Nursing DocumentationNursing Progress Notes Are usually narrative description of patient’s

progress toward goal achievement. Includes assessment of the client’s mental

and physical condition, client activities, nursing interventions and client responses, visits by other member s of health team, and treatments performed by physicians that affect nursing care.

A section for writing descriptive progress notes is included in the patient’s chart.

Two most prevalent methods of writing progress notes are the chronological narrative and the SOAP format.

Chronological Narrative Charting Is the traditional charting format. Nurses write notes in paragraph form

during the shift. Events and patient’s responses are

written in chronological order.

SOAP Charting SOAP is acronym for Subjective data,

Objective data, Assessment, and Plan. SOPIER is used by some institutions

where I represents Intervention, E for Evaluation, and R for Revision.

implementing the nursing care plan

Documents

nursing interventions

nursing activities nurse

nursing diagnosis

interdependent nursing

planned nursing strategies

job nurse

head nurse

medical plan