the nursing process care planning michele archdale

THE NURSING PROCESSCare Planning

Michele Archdale

Care Planning

The Who, What, Why, and How of Care Plans for Nurses

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July 2010 2

A care plan is a document that outlines the nursing care that is planned for a patient.

Care plans evolved as a way for nurses to monitor nursing care and to communicate between incoming and outgoing shifts (Arets and Morle, 1995).

Care plans ensure that nursing care is planned, measured, documented, and evidence-based, and that outcomes are examined regularly (Greenwood, 1996).

What is a Care Plan?

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• Care plan formats vary from facility to facility.

• Generally, a care plan has sections that correspond to each step of the nursing process (ADPIE). You will document your observations and choices in the spaces.

• Usually, there is a care plan for each nursing diagnosis.

What Does a Care Plan Look Like?


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Sample Care Plan


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‣ Care planning is an ongoing, dynamic process. It makes no sense to make a care plan, and then leave it to collect dust. As the patient’s situation changes, so should the care plan.

‣ Care plans are not static. They are modified, updated, corrected and extended according to the patient’s changing needs.

Care Planning is Ongoing


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Your patient is 5 days post-op for total knee replacement. Her care plan, written 1 day post-op, states that she requires a one-person assist to ambulate. However, she has progressed to ambulating independently with a walker.

Does it make any sense for the care plan to indicate that she requires a one-person assist?

Of course not. This is why we reassess and update the care plan on a regular basis.

Example


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• Nurses develop individualized care plans for each patient with a series of defined steps called the nursing process.

• Therefore, to develop care plans, you have to know what the nursing process is.

Where Do Care Plans Come From?


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“The purpose of the nursing process is to provide a systematic approach for processing patient care information for handling actual or potential patient care problems.”

(Huckabay, 2009)

The Nursing Process: Purpose


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The nursing process addresses the need for nursing care to be:

Holistic Individualized Evidence-based Documented

The Nursing Process: Background


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• Historically, the nursing process has had several formats. The gold standard is ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation) (Pesut & Herman, 1999).

The Nursing Process: ADPIE


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Remember the 5 steps of the nursing process with this acronym:

ADPIE

The Gold Standard


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• Assessment

• Diagnosis

• Planning

• Implementation

• Evaluation

What Does ADPIE Stand For?


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Assessment

• History taking• Collecting data• Examination and observation• Validating data• Organizing data• Identifying patterns/testing first impressions• Reporting and recording data

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• Subjective data – stated

• Objective data – observed

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Resources

• Client • Other individuals• Previous records• Consultations• Diagnostics studies• Relevant literature

• Assessment This is what you find when you examine and talk to the patient.

It is an ongoing process. (Wright, 2005).

For example: “The patient has dry, cracked lips, dry mucous membranes and low urine output. The patient’s skin turgor is slow to return and the patient states that he is thirsty.”

The Nursing Process (ADPIE): Assessment


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• Diagnosis (defining problem)This is a description of what the nursing problem is. The language may be your own, or chosen from a list of over 200 standardized nursing diagnoses from the North American Nursing Diagnosis Association (NANDA) (Palese, et al., 2009).

The Nursing Process (ADPIE): Diagnosis


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Nursing Diagnosis

– Analysing and interpreting information obtained to identify actual or potential problems of the client the nurse can help to resolve or prevent through nursing intervention.

– made after a client's information has been obtained and compared with normal functioning for that client.

– The nurse makes assessments or inferences about the significance of the information and identifies the client's problems.

• (Funnell, Rita. Tabbner's Nursing Care, 5th Edition. Elsevier Australia, 12/1/2008. p. 230). • <vbk:978-0-7295-3857-2#outline(19.5.2)>

• Your assessment findings are often included in the nursing diagnosis, using the phrase “as evidenced by”.

• The nursing diagnosis is what you determine to be an actual or potential reaction to the patient’s state of being. The diagnosis also helps guide you towards appropriate interventions.



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• The nursing diagnosis is not a medical diagnosis, such as diagnosis of a disease or health condition. Rather, it is a description of the patient’s response to their current situation.

• That is, “multiple sclerosis” is a medical diagnosis, not a nursing diagnosis. “At risk for powerlessness due to disease process” is a nursing diagnosis (NANDA, 2010).



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For the patient we assessed earlier, the NANDA nursing diagnosis would be:

Deficient fluid volumeYou would individualize by adding “as evidenced by dry mucous membranes, low urine output, slow-to-return skin turgor and expressed feelings of thirst”.

This is our nursing diagnosis!(Gulanick et al., 2006)



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Planning

• Setting priorities• Establishing clear goals and outcomes for the patient to

achieve.– Choosing nursing interventions to meet those outcomes.

• Determining interventions• Care planning• Time and resource management• Documentation.

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Priorities

• Enables the nurse and patient to make the best use of time, energy, and health care dollars.

• Designs the plan with the patient and significant others not for them.

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General Guidelines for Setting Priorities

• Take care of immediate life-threatening issues.

• Safety issues.• Patient-identified issues.• Nurse-identified priorities based on

the overall picture, the patient as a whole person, and availability of time and resources.

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Implementation• Putting the nursing plan into action (nursing

interventions)• the actual performance of the activities that

have been selected to help the client achieve the set goals.

• The client's needs are reassessed continuously during the implementation stage

• Any new needs can be identified and the nursing care plan can be modified or adapted.

PlanningDescribes what you expect will occur for the patient. It can be helpful to think of this step as Goals or Outcomes.

ImplementationDescribes what you plan to do to meet the patient’s needs, guided in part by your NANDA diagnosis (Hughes, et al., 2008). Sometimes termed Interventions.

The Nursing Process (ADPIE): Planning and Implementation


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• Use the acronym SMART to guide your Planning and Implementation:

Specific

Measureable

Achievable

Realistic

Time-specific(Wright, 2005)



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Nursing Outcome Classifications (NOC) is standardized language available to describe Planning, similar to NANDA for Diagnosis.

For our patient example, appropriate NOC terminology for Planning (desired outcome) is:

Fluid balance

(Kautz et al., 2006)

The Nursing Process (ADPIE):Planning


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Nursing Interventions Classification (NIC) is standardized language available to describe Implementation, again similar to NANDA for diagnosis.

For our patient example, appropriate NIC terminology for Implementation is:

Measure intake and output

(Kautz et al., 2006)

The Nursing Process (ADPIE):Implementation


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• For our patient with a nursing diagnosis of deficient fluid volume, our plan is to achieve fluid balance, and so far, our implementation is to measure input and output.

• What other interventions might be appropriate?

The Nursing Process (ADPIE): Implementation Practice


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• Additional interventions: Daily weights Vital signs Encourage oral fluid intake Administer IV fluids as ordered

The Nursing Process (ADPIE): Implementation Practice


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• Planning and Implementation must be evidence-based.

• You communicate the evidence base for your choices by giving a rationale. In nursing school, you need to provide the rationale and references to show your instructors that you are utilizing the nursing process. Most workplaces do not require a stated rationale or references on care plans.



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A rationale for measuring urinary output for the patient in our example is:

Reduced urinary output can indicate dehydration. Normal urinary output is considered to be >30 mL per hour for an adult (Berman, et al., 2008).



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Implementation - Setting Priorities

1. Make initial rounds.2. Verify critical information 3. Identify urgent problems4. List problems 5. Determine interventions that would best

address the problems6. What can the patient do themselves?7. Worksheet

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Evaluation

• Determining outcome achievement• Identifying the variables affecting outcome

achievement• Deciding whether to continue, modify, or

terminate the plan

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• Thinking and collecting information about the patient’s responses after some nursing care is provided.

• Working with the patient to determine whether the patient’s outcomes have been met and how well they have been met.

• EvaluationThis is when you review your patient’s progress to see if

your interventions were effective.

• Your evaluation may indicate you need to change your approach to achieve your planned goals (outcomes).

(Wright, 2005)

The Nursing Process (ADPIE): Evaluation


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• Perform evaluations as often as necessary to keep track of your patient’s progress and changing needs. Usually, this translates to once a shift (or more often) in an acute, in-patient setting, and monthly or quarterly in a nursing home.

The Nursing Process (ADPIE): Evaluation


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• You use the nursing process to generate care plans. Care plans must be documented.

• Care plans are legal documents and should be treated accordingly.

• When you make additions or changes to a care plan, initial all entries to ensure you are recognized for your contribution, and you leave a record of your actions.

Documentation


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• DO: Sign (or initial) and date all changes or entries to the care plan so that it is clear who made the revisions or changes.

• DO: Review your care plan on a regular basis. The frequency of your review really depends on the setting, the situation and your employer’s policies.

Documentation Do’s


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• DON’T use white out on a paper care plan. Cross out an error with one line (so your error remains legible), write the word ‘error’ and add your initials. For electronic records, follow your facility’s policy.

• DON’T attempt to delete or remove unsuccessful interventions from a care plan. You will adapt your care according to your evaluations, and this should be reflected in your documentation.

Documentation Don’t’s


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‣ You may want to document all of your findings, normal or otherwise, regardless of the facility’s policy. Your employer’s policy is important, but no one should fault you for doing more than the minimum requirement.

‣ Ensure that you cover yourself legally with your documentation. Ask yourself if you could accurately describe a situation years later in court, based only on your charted notes.

Documentation


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Documentation: ExamplesPoor Charting

• Skin normal

• Heart sounds normal

• Pulse good, 65 BPM

• No documentation of pain

• Skin pink, warm, dry and no visible injuries

• S1, S2 heard with no adventitious sounds

• Left radial pulse strong and regular, 65 BPM

• Patient denies any pain at present


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Accurate Charting

Care plans:‣ Define how we look at patients and approach their care.

‣ Force us to really think about what we are doing with patients, and why we are doing it.

‣ Provide a structure for constant reassessment of the plan for patient care (Wright, 2005).

‣ Are a valuable communication tool among nurses and other health professionals (Greenwood, 1996).

‣ Help maintain consistency of care.

What Are Care Plans REALLY For?


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‣ Some facilities have electronic care planning resources.

‣ Some believe that the electronic care plan will revolutionize care planning, and enhance the care planning process.

‣ Some feel that nursing care plans are unnecessary.

(Greenwood, 1996; Kennedy, et al., 2009; Lieber, 2010)

Modern Care Planning


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‣ Most experts, including nursing licensing bodies and regulators, believe that care plans are essential (Greenwood, 1996).

‣ Imagine working in an unfamiliar area, or starting an orientation period on a new floor. An existing care plan allows you to plan your care. It also helps other, experienced nurses know how to help you.

Modern Care Planning


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Remember, your Planning and Implementation should be:

Specific

Measureable

Achievable

Realistic

Time-specific(Wright, 2005)

Remember to be SMART


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‣ Not every workplace enforces the use of care plans. You can still use them, regardless of policy.

‣ Care plans will improve the quality of your patient care, even if you have to manually add brief care plans to your progress notes.

Day-to-Day Use of Care Plans


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‣ NANDA, NOC and NIC provide a universal language for care plans, which improves consistency and understanding among caregivers.

‣ You may find the same interventions are recommended in different care plans for the same patient. Try to not repeat yourself when preparing care plans.

(Adams-Wending, et al., 2008)

Day-to-Day Use of Care Plans


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Books:

Crofton, Christine, & Witney, Gaye, ‘Nursing Documentation in Aged Care’, Ausmed Publications, 2004.

Richmond, Jennifer,. ‘Nursing Documentation – writing what we do’, Ausmed Publications 1997.

Free access to information about NOC and NIC: http://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/noc.htm

NANDA web site: http://www.nanda.org/

Contains the NANDA diagnoses and classifications for 2009-2011: http://www.amazon.ca/gp/product/1405187182/ref=pd_lpo_k2_dp_sr_3?pf_rd_p=485327511&pf_rd_s=lpo-top-stripe&pf_rd_t=201&pf_rd_i=0323039545&pf_rd_m=A3DWYIK6Y9EEQB&pf_rd_r=1H2K1EM4DGHSEYBFC6DE

Care Plan Resources


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Free download of a searchable NANDA diagnosis program for PDAs: http://www.pdacortex.com/Nursing_Diagnosis_Download.htm

Care planning reference book: http://www.amazon.com/exec/obidos/ASIN/0323016278/medismartcom

Free online care plan generator – uses NANDA, NOC, and NIC: http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/

Free online care plan generator – uses NANDA, NOC, and NIC: http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/H-O.html

Care Plan Resources


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Care planning reference book: http://www.amazon.ca/Nursing-Care-Plans-Diagnosis-Intervention/dp/0323039545

An interactive CD-ROM from Mosby to assist you in producing over 90 different care plans: http://www.amazon.com/exec/obidos/ASIN/0323024025/medismartcom

A paid membership site: http://www.careplans.com/

Care Plan Resources


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Free sample care plans: http://www.medi-smart.com/carepl10.htm

Subscription site for nursing home [residential] care planning: http://www.cncplan.com/

Care planning specifically for MS patients: http://www.cnsonline.org/www/archive/ms/ms-07.html

Free tips and comments on nursing care plans: http://www.virtualnurse.com/blog/category/nursing-care-plans/

Care Plan Resources


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Application for iPod Touch or iPhone to help formulate care plans: http://itunes.apple.com/ca/app/handbook-nursing-diagnosis/id311016899?mt=8

Nursing diagnosis handbook: http://www.amazon.ca/gp/product/0323048269/ref=pd_lpo_k2_dp_sr_1?pf_rd_p=485327511&pf_rd_s=lpo-top-stripe&pf_rd_t=201&pf_rd_i=0323039545&pf_rd_m=A3DWYIK6Y9EEQB&pf_rd_r=1H2K1EM4DGHSEYBFC6DE

Care Plan Resources


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• Adams-Wendling, L., Paimjariyakul, U., Bott, M., & Taunton, R. L. (2008). Strategies for translating the resident care plan into daily practice. Journal of Gerontological Nursing, 34 (8), 50-56.

• Arets, J. & Morle, K. (1995). The nursing process: an introduction. In: Basford, L., Slevin, O., Arets, J., et al. eds. Theory and Practice of Nursing. Edinburgh, Scotland: Campion Press. pp. 304-317.

• Berman, A., Kozier, B., Erb, G., & Snyder, S.J. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (8th ed.). Upper Saddle River, New Jersey, U.S.A.: Pearson Education, Inc. Accessed at www.statref.com on 17 June 2010.

• Castledine, G. (2010). Critical thinking is crucial. British Journal of Nursing, 19 (4), 271.

• Doenges, M. E., Moorhouse, M. F., & Geissler-Murr, A. C. (2004). Nurse’s pocket guide: Diagnoses, interventions and rationales (9th ed.). Philadelphia, Pennsylvania, U.S.A.: F.A. Davis Company.

References


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• Greenwood, D. (1997). Nursing care plans: Issues and solutions. Nursing Management, 27 (3), 33-40.

• Gulanick, M., Myers, J. L., & Galanes, S. (2006). Nursing care plans: Nursing diagnosis and interventions, 6th ed. Toronto, Ontario, Canada: Mosby.

• Henderson, V. (1982). The nursing process: is the title right? Journal of Advanced Nursing, 7 (2), 103-109.

• Huckabay, L. M. (2009). Clinical reasoned judgment and the nursing process. Nursing Forum, 44 (2), 72-78.

• Hughes, R., Lloyd, D., & Clark, J. (2008). A conceptual model for nursing information. International Journal of Nursing Terminologies and Classifications, 19 (2), 48-56.

• Kautz, D. D., Kuiper, R., Pesut, D. J., & Williams, R. L. (2006). Using NANDA, NIC, and NOC (NNN) language for clinical reasoning with the outcome-present state-test (OPT) model. International Journal of Nursing Terminologies and Classifications, 17 (30), 129-138.

References


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• Kennedy, D., Pallikkathayil, L., & Warren, J. J. (2009). Using a modified electronic health record to develop nursing process skills. Journal of Nursing Education, 48 (20), 96-100.

• Lieber, H. S. (2010). Balancing act: Technology must be part of an overall patient-care plan. Modern Healthcare, 40 (9), 18.

• North American Nursing Diagnosis Association (2010). Nursing diagnosis frequently-asked questions. Retrieved from http://www.nanda.org/NursingDiagnosisFAQ.aspx.

• Palese, A., De Silvestre, D., Valoppi, G., & Tomietto, M. (2009). A 10-year retrospective study of teaching nursing diagnosis to baccalaureate students in Italy. International Journal of Nursing Terminologies and Classifications, 20 (2), 64-75.

• Pesut, D. J., & Herman, J. (1999). Clinical reasoning: The art and science of critical and creative thinking. New York, New York, U.S.A.: Delmar Cengage Learning.

• Wright, K. (2005). Care planning: An easy guide for nurses. Nursing and residential care, 7 (2), 71-73.

References


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http://www.nanda.org/NursingDiagnosisFAQ.aspx

PRINCIPLES OF DOCUMENTATION

• “All forms of documentation by a nurse recorded in a professional capacity in relation to the provision of care. • Written• Electronic Health Records• Audio• Video• Emails• Faxes• Photographic images• Observation Charts• Check lists• Communication books• Incident Reports• Clinical nursing notes

Professional Documentation

• Patient assessment tools and charts• Diagnosis – past and present• Nursing notes• Test results• Written instructions• Drug orders• Client referrals• Clinical pathways – health risk factors• Care plans – patient’s progress• Computerised reporting

Nursing Records or Reports

• Compliance with ANMC competency standards• High standard of care• Evidence of nursing care• Continuity of care• Improved communication and delivery of information• Accurate account of assessment, care planning,

treatment and care evaluation• Ability to look back and assess achievements / goals• Early detection of variances

Documentation promotes

• As a tool – evidence based practice• Communication method – reliable &

permanent• Demonstrates responsibility & accountability –

evidence of care received• Legal requirement – Legislation• Quality improvement tool• Health research• Track resources, efficiencies in management

WHY DOCUMENT?

Documentation should be a record of first hand

• Knowledge• Observation• Actions• Decisions• Outcomes

Principles for Documentation

• Registered Nurses (RN)• Enrolled Nurses (EN)• Clients• Health Professionals• Other care providers

Who should document?

• All aspects of nursing care• Collaboration and interventions from other

health professional / care providers• Subjective and Objective information• Observation, assessment, actions, outcomes• Variances in outcome or usual protocol• Rationale for decisions and actions• Critical incidents that involve the client

What to document?

• As a time line recording actions and events• In a timely manner• The action or event• Nursing or allied health professional

interventions• Variances to expected outcomes• Emergency situations• Retrospectively as a late entry

When to document?

• Comprehensive & flexible• In a concise manner, accurate and true• Clearly and legible – Can anyone read your writing?• Permanent– Never in pencil always in pen. At certain times

colours are required as per hospital policy. • Identifiable – sign and write your name• Current – date and time• Confidentiality and Privacy issues• Evidence based – not speculation• Avoid abbreviations• Understand and use appropriate terminology

How do you document?

• Health care workers may only be present for short periods of time – continuity issues

• A multidisciplinary team, that may never actually meet

• Health care records must act as a communication tool

Effective communication

• Be accurate• Current• Relevant• Factual• Organised• Concise• Complete

DOCUMENTATION MUST!!

• Fragmented care• Repetition of care• Delayed interventions• Omitted interventions• Delayed recovery

Consequences of Poor Documentation

• Every activity of the nurse in the performance of her nursing services is subject of potential analysis by the law.

• The laws are made to protect the health and welfare of the public.

• Ignorance of the law is no excuse. When a law exists and the nurse violates it, the nurse is subject to criminal charges.

• Always document appropriately – If it’s not written down it did not happen! - you could need to refer to your notes at any time in the future when you can not recall what happened.

Legal responsibilities

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Preparing for Report

• Show up on the unit in time to prepare for report / handover.

• Review charts briefly before report.

• Be ready to listen.• Use worksheet to organize

reported data.

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Getting Report / handover

• Worksheet 1. Organizes data 2. Cues to information

3. Worksheet for the day• Do not become totally dependent on

worksheets

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Giving Report

• Use your worksheet• Give basic info first• Be specific• Evidence based statements only• Be descriptive• Stress the abnormal

the nursing process care planning michele archdale

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