Nursing Assessment of Patients

Creating Care Plans that serve the patient and charts that are

representative of patient conditionSusan Collins, RN FN

Where to begin?

• Patients usually enter the healthcare system with an illness or injury

• Patients using the CAM model may access healthcare more often for wellness and prevention initiatives.

• How ever a patient enters the system at a given time, the plan of care for them in the patient centered care model is based

on meeting their needs.

Purpose of a Plan of Care

• Care plans are an important part of providing quality patient care. They help to define the nurses' role in the patient's treatment, provide consistency of care and allow the nursing team to customize its interventions for each patient.

• Additionally, it promotes holistic treatment of the patient and helps define specific goals for the patient.

Why plan for care?

• Care plans are an important part of providing quality patient care. They help to define the nurses' role in the patient's treatment, provide consistency of care and allow the nursing team to customize its interventions for each patient. Additionally, it promotes holistic treatment of the patient and helps define specific goals for the patient.

• Serve as a roadmap for patient care

Consistency of Care is good for patients!

• Another important function or purpose of nursing care plans is to provide consistency of care across time.

• If a nursing care plan is in place, nurses as well as all types of healthcare providers from different shifts or different floors can utilize this information to provide the same quality and type of interventions to care for patients, thus allowing patients to receive the most benefit from treatment.

Promotes Holistic Care

• Nursing care plans, while created primarily for the nursing team, can also be used by interdisciplinary team members to promote cohesive and comprehensive holistic treatment of the patient.

• If other team members are aware of the goals and interventions laid out in the nursing care plan, they can better work in conjunction with, rather than counteractive to, the nursing staff.

• For example, a physical therapist who is aware that the patient is at risk for depression due to decreased social interactions may choose to have that patient participate in exercise in a group during physical therapy, instead of exercising alone.

What is a care plan ? 4 basic elements

• What is the patient’s health care problem?• Determine an approach to assist or treat• Set a goal or desired outcome• Evaluate the response

SOAP Format

• Patient assessments are found with various catchy titles. The basic one is the SOAP format.

• It is most often used in charting, and sometimes even with the letters out to the side. It is so well understood that no one wonders “what is that?”

• SOAP format helps in creating care plans by identifying patient needs.

How is SOAP used in charting?

• The patient is assessed using the indicators of• Subjective• Objective• Assessment• Plan• Provides a format to offer consistent care and

uniform assessment.

Subjective

• S=Subjective : What do you hear the patient, or subject, saying about what is happening? – Example: “I can always tell when my blood

pressure is up, I get the worst headaches.”

Objective

• What does the nurse see happening at the time that relates to the problem? – Ex: Patient noted to be holding her forehead when

observed upon admission. – Ex: Wound drainage purulent.– Ex: Face flushed and patient observed picking at

her sheet.

Assessment

• What the nurse or caregiver does to investigate the complaint or complete an ongoing assessment of the problem. How is this situation evaluated?– Ex: Take BP every 4 hours and PRN c/o headache– Ex: Check dressing q2h and redress PRN

Plan

• The plan is exactly as you suspect, what is the plan to help this patient?

• Example: If a patient has asthma, then a Ventolin rescue inhaler should be administered when symptoms occur or before exertion.

• May include short and long term actions

SOAP has been upsized too!

• Some facilities use the version SOAPIER to chart and even to create care plans.

• SOAPIER charting is covered on HSE competencies. It is best suited to charting rather than care plans, as care plans tend to be concise and either in a flip chart central location or checkpoints on a computer program.

intervention

• measures you have taken to achieve expected outcomes. – Ex. Patient with CHF experiences ankle edema

after sitting up in the chair for the afternoon, so an appropriate intervention would be provide a period of rest with his feet elevated for 30 minutes after sitting.

evaluation

• Analysis of the effectiveness of your interventions.

• Did the patient’s ankle edema decrease after elevation?

revision

• Changes from the original care plan that could more effectively benefit the patient.

• EX: have the patient limit sitting up in a chair to 45 minutes, followed by elevation of the lower extremities.

Example of a chart entry

• [Nursing Diagnosis]#4 Acute pain related to surgical incision.S: 2245 patient states, "No" when asked if she has pain. At 2335 patient states, "It hurts."O: Patient reports incisional pain as 7/10 on scale of 0 to 10.A: Patient is in pain and needs pain medication.P: Give pain meds as ordered.I: Patient given morphine 2mg IV at 2335.E: Patient states pain as 1/10."

How could that same problem look on a care plan?

• Problem:postoperative pain

Observations:Pt c/o pain verbally

Pt resists movementInterventions:Assess pain level q2h and PRNMedicate per physician orders

with analgesicsTurn and reposition with assist q2hAssessment: Pt assessed using

pain scale and v/s

Create a care plan part I

• Nursing Diagnosis: At risk for hyperglycemia due to carbohydrate intake and overweight

• Define a specific problem– Patient weight is 30% above ideal weight

• Identify a measurable goal related to the problem– Patient will limit carbohydrate intake to 90 gm per

day

Care Plan pt II

• Establish an intervention to help achieve the goal– Instruct patient in interpreting food labels. – Inform patient about fiber– Instruct patient in how to deduct fiber from carb count– Assist patient in establishing a format for recording carb intake

• Evaluate the interventions for efficacy– Record data • Pt observed reading a food label and correctly

informing niece of his carb count

View It

• http://www.youtube.com/watch?v=nSbdPJz-xX0

• Nursing School: Nursing Care Plans• hdryver

Try It!

• Using the template provided, fill in a sample care plan for a problem using the assigned disease.

Plan It!

• Care plans and charts are vital ways that all areas of healthcare providers communicate for the safety and benefit of the patient!

• Be accurate, concise, tidy, and impartial in your notes and plans