Nursing care plan ppt final draftPresentation Transcript
You too can survive nursing school!!!!!!!!!!!!!!!!!"http://www.youtube.com/embed/PgvVTXhHz58
What is a care plan Why do nurse write care plans What are the different parts of a care plan What other paper work will I need to know How am I evaluated When is everything due
Provide a direction for individualized patient care. Provide continuity of care for the patient with all hospital departments. Provide documentation on patient and family needs.
Provides acuity for staffing needs. Provides reimbursement for insurance which was started by Medicare and Medicaid and now used by all insurance companies. This is how hospitals and patients receive payment. http://youtu.be/Ll3uipTO-4A
Actual—What is actually wrong with the patient. Psychosocial- Nursing Process and Self‐ConceptRelated NANDA Nursing Diagnoses • Ineffective Role Performance • Body Image Disturbance • Chronic low self‐esteem • Self‐esteem disturbance • Situational low self‐esteem • Personal Identity disturbance
Related NANDA Nursing Diagnoses • Ineffective Role Performance • Body Image Disturbance • Chronic low self‐esteem • Self‐esteem disturbance • Situational low self‐esteem • Personal Identity disturbance
What is your patient at risk for based on their nursing diagnosis. Nursing diagnoses that are in the "risk for" categories may not need the AEB portion of the statement, since there is no actual evidence. However, you should avoid using too many "risk for" diagnosis. One or two, out of eight to ten, is acceptable. http://www.atrane.org Link to site
Nursing diagnosis Goals for patient and family Nursing care Nursing scientific rational Evaluation
Begin with a complete assessment of your patient. Get as much information as possible from the chart, such as lab data, x-ray reports, physician history and physical exam
Subjective-This is what your patient tells you. ― My head hurts‖ States on scale of 1-10 Myhead hurts at 8.Objective- This is what you see.Patient rubbing head.
This helps you decide what is really wrong with your patient. You must listen to know what they are not telling you.
BMPNa L124 136-145 mEq/LK H5.8 3.5-5.1 mEq/LCO2 25 23-29 mEq/LCl 101 98-107 mEq/LGlucose H107 74-100 mg/dLCa 10.1 8.6-10.2 mg/dLBUN 17 8-23 mg/dLCreatinine 0.9 0.8-1.3 mg/dLKey: L=Abnormal Low, H=Abnormal High, WNL=Within Normal Limits, *=criticalvalue--------------------------------------------------------------------------------Specimen(s) Collected: 2/10/08 14:30 Lab Accn No. 223457Specimen: Blood Date Reported: 2/10/08 15:30Test Name Patients Results Ref. Range UnitsHGB L7.0* 14.0-18.0 gm/dLHCT L21.1 42.0-52.0 %Comment: Hgb of 7.0 and Hct of 21.1 reported to Dr. J Smith at 15:15 on 2/10/08 by J.DoeDate Reported: 2/10/08 18:40HGB A1c
It is not a medical diagnosis A nursing diagnosis is the plan of care for your patient which all member of the staff will follow as they care for the patient.
The nursing diagnosis – From NANDA-1 list ―Related To‖ (R/T)- what is causing the nursing diagnosis. Defining Characteristics- ―AEB‖ ( as evidenced by) signs and symptoms better known as subjective and objective data
A goal is what you want your patient to achieve. I has to be measureable with a time frame noted. An example is: You will graduate in 3 Semesters
Must be : Patient centered Clear and concise Observable and measurable time limited Realistic one behavior /goal determined by patient, family, nurse together.
MEASURABLE NON -MEASURABLE Identify Describe Perform Know Relate State Understand List Verbalize Appreciate Demonstrate Share Think Express Communicate Accept Exercise Cough Feel Walk Stand Sit Discuss Has an increase in Has a decrease in Has an absence of
What are you going to do to help your patient reach their goal. This is what you do daily for your patient. If you give your paper to a peer would they be able to follow your intervention or plan of care.http://www.youtube.com/watch?v=xRFIDg9BPnQExample: If you study hard then you willgraduate
This is the scientific reason you did this for your patient. You must tell us (cite) where you got your information. This could be your from your books or a reliable internet source. I studied and went to class. I sat on the front row and took notes.
Poor Procrastination OnAttendance Assignments Failing To Take NotesNegative orthoughts Following teacher instructions Poor time management
Did your patient reach their goal in the time frame that you allowed for them Did your patient not reach their goal and do you need to extend the timeframe or is this an unreachable goal and you need to start over? Student passed in 3 semesters and met goals Student did not pass in 3 semesters and goal not met.
We have covered every aspect of this paper
This is the form you will turn in daily and it will help you write your care plan
This form will be given to you on Friday after clinical. If your instructor is very busy, you will receive it on Monday.
Nursing Diagnosis using subjective and objective Data Nursing rational andevidence E valuation met Or not
What is a care plan? What is a nursing diagnosis What is a rational What is an evaluations What is an intervention How long is an intervention How long is a goal
NURSING CARE PLANSSTUDENT____________________________________PATIENT INITIALS____________ROOM NUMBER__________DATES________________ ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION (supportive data) (patients need) (nursing care needed) (documentation of care) (status of goal)FACTUAL DATA PROBLEM STATEMENT NURSING PLAN FOR PROBLEM DOCUMENTATION STATUS OF THE GOALSupports your problem. This This is the name you give the Ask yourself, “What can I do for Ask, “What will I document?” Ask yourself, “Did Iinformation has to be problem. Ask yourself, the problem?” Any information that pertains to accomplish my goal?”current, or perhaps past “What is the problem?” the problem. 1. Look at your goal & askhistory and NOT “make You can use the NANDA list These are not to be numbered. yourself a question relatedbelieve”. Think of it as of problem statements OR if This is your actual narrative to it - whether your Goal charting notes just like on your was met completely, metsupportive data that proves none apply, make a problem Think about the following: Assessment Sheet in Level 1 or partially, or not met at all.you have an actual or statement using one of the Observations you make related to Write this down.potential problem. It must words: this problem, (include assess- charted observations in the nurses notes in the chart. NOTE: This is 2. Answer the question in ahave at least 2 pieces of Alteration Impaired ment of the pt re: to the body Summarized Evaluation NOT a restatement of your plan in theinformation to support Deficit Ineffective system re: this problem, diag- past tense! Also it DOES NOT have to Statement and relate it toproblem. Dysfunction Intolerance nostic tests, and reporting of address each part of the plan. DO the M easurable Part of the Excess findings to charge nurse. (Use NOT number this section or leave Goal. Write this down.Ask yourself, “Why do I your senses). spaces. Also any conclusions, or 3. Does the problem orthink this is a problem?” Refrain from using: Tasks you can do (things you can judgments that are improper in potential for the problem Decreased Cardiac Output* do to prevent, repair, or reduce still exist? Write this down. Disuse Syndrome charting are not proper here.Think about your pt’s: the problem). This includes Students have best results in 4. Then, state if you will Impaired Gas Exchange* Continue with your plan -1. Medical Diagnoses Impaired Physical Mobility medication adm., oxygen, learning how to word this section dressing changes, turning, either as stated or as S & S from Dx that your Decreased Mobility (of any kind) when they do not even look at the enema, catheter insertion, revised or Discontinue Plan. pt is having right now Risk for Infection** planning section. Write this down. If no S&S right now, just Risk herapeutic Regimen* T of Ineffective Management of nutrition, fluids, etc. NOTE: You must have list the Dx as support Teaching of patient & family Document: Date/Time something to back up this *T hese problems must have specific (includes not only what the 1. Observations you made evaluation in your2. Medication List data, measurements, lab tests, etc. in doctor orders but what you as 2. Reporting observations and documentation in the Side effects? order to use these problems. the “nurse” will teach the changes in condition to Implementation column patient. Also should include appropriate personnel (Implementation supports or **T here may be some very specific proves your evaluation3. Abnormal Lab? cases where it may be applicable. how you will determine the 3. Care given to the patient patient’s understanding of the statement). T hink, what can an “infection” can 4. Response of the pt to the care cause? Use that as a problem instead. teaching.) 5. Results of your actions, Examaple: diagnostic tests, medications Goal was partially met. The Goal: What do you plan to Be very SPECIFIC and very administered, etc. patient washed his face but did not accomplish? Must be pt - THOROUGH. Include details like 6. Teaching specific to patient brush his teeth himself. The centered, AND specific, how much, frequency (how often), problem still exists. Continue meds, needs, problems, with the plan as revised. measurable, attainable, etc. preventative care. realistic, & time-sequenced. DATE REVISIONS OR ADDITIONS EVERY DAY! DATE ENTRY EVERY DAY!
Mr. Goodpatient is a 60 year old male admitted with a diagnosis of acute myocardial infarction.This is the data collected during the assessment.Subjective: Mr. G. is complaining of severecrushing chest pain unrelieved by rest whichhas lasted for 2 hours. The pain is substernaland does not radiate. He states the pain is a 9on 0-10 pain scale. He says he smokes 2 packsof cigarettes per day, is a manager at anelectronics firm, and that his father died @age59 of a heart attack
Objective Data: Vital signs: Pulse 110 and irregular BP 90/68 Resp. 28 His cardiac monitor shows sinus tachycardia with frequent PVCs His heart sounds are normal except for the irregularity and his lungs are clear. He is pale, diaphoretic, and holding his chest.
DeWitt, S. (9th ed), Medical- Surgical Nursing Concepts and Practice, St. Louis, Mo., Saunders PowerPoints.http://emievil.hubpages.com/hub/7-Bad-Study-Habits-A-College-Student-Must-Not-HaveMicrosoft clip art and microsoft officeCase studies from previous classes and patientfiles.