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•Describe the Nursing Process as the framework for a patient Plan of Care.
Critical Thinking Model
•Describe how Plans of Care are created from Nursing Diagnoses.
Common Language
•Describe how the caritas process applies to the Interdisciplinary Plan of Care (IPOC).
Theory of Human Caring
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*The Nursing Process, a critical thinking model, includes the patient-specific Assessment, Diagnosis, Planning, Implementation and Evaluation, and is the foundation for a well-developed IPOC.
*Recognizing the uniqueness of each patient and the provision of individualized care is accomplished through the use of comprehensive and standardized language (I.e.: Nursing Diagnosis).
*The Caritas Process (of the Theory of Human Caring) is used as an expressive tool to guide and further deepen the meaning of the Plans of Care developed for each patient.
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* Nursing Process - the diagnosis and treatment of
human responses to actual and potential health problems. American Nurses Association (ANA) Social Policy Statement of 1980
Assess
Plan
Implement
Evaluate
Nursing
Diagnosis
The Nursing Process includes: Assessment Diagnosis Plan Implementation Evaluation
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All caregivers… 1. Collects data
2. Identifies patient needs
3. Establishes goals & creates measurable outcomes
4. Selects interventions to assist patient in achieving the outcomes & goals
5. Evaluates the outcomes
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Assessing
Diagnosing
Planning Implementing
Evaluating
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*Registered Nurse
*Respiratory Therapist
*Physical Therapist
*Occupational Therapist
*Speech Therapist
*Registered Dietitian
*Specialists: Wound Care, Diabetes, Stroke, etc.
*Infection Control
*Care Manager & Social Worker
*Pharmacist
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*Determine appropriate
plan
*Provide standard language
*Drives interventions and
patient outcomes
*Consistent and accurate
documentation
http://www.nanda.org/NursingDiagnosisFAQ.aspx
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*Three major elements of the Caring
Theory
caritas process
transpersonal caring relationship
caring occasion/caring moment
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Larry, a 65 year-old male, is 24 hours post-open
cholecystectomy. He has a history of smoking, COPD,
DVTs, and an allergy to penicillin. He states he “fell
once” a few weeks ago. He is homeless, and states he
is not interested in receiving any information on
outpatient clinics for follow-up care when he is
discharged. A clear liquid diet was not tolerated by
Larry; he complains of severe nausea and abdominal
pain 8 out of 10 on the pain scale. You note that Larry
quickly becomes fatigued with any physical activity.
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*The RN notes that Larry has a history of falls
* The Care Manager notes that Larry is homeless and
is refusing follow up care
* The RN notes that Larry needs moderate assistance
with his hygiene needs
*The Registered Dietitian notes that Larry is not
tolerating his diet
*The RN notes Larry’s pain level remains high despite
current therapy
*The Physical Therapist notes that Larry has
difficulty breathing and becomes fatigued with
activity
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*Risk for Injury
*Discharge Needs
*Self Care Deficit
*Nutritional Deficit
*Pain
*Activity Intolerance
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*Think of the Plan of Care as a living document that evolves
throughout the patient’s stay
*An assessment by one discipline could potentially identify
a problem/goal in another area
*For example, PT’s findings uncovered Larry’s respiratory
problem
*Follow up to identified problems/goals can – and should -
be performed by multiple disciplines as appropriate
*Can I document on the same goals or interventions as another
discipline? Yes!
*Can I remove or add goals or interventions to the Plans of
Care, even if identified by another discipline? Yes!
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*Through assessment and documentation of
individual patients, plans of care are suggested
to the caregiver
*The first step in prioritization is that the
caregiver evaluates the recommended plans,
accepts them or does not accept them, and
indicates goals. You also have the ability to
add care plans that are not suggested if
applicable.
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*Plans of care should be specific to the
patient and specific to why they are
hospitalized. For Example:
*A patient with a history of hypertension, but is
not admitted for HTN this visit, should not have a
plan of care related to elevated blood pressure –
only if it is an issue this hospitalization.
* If an elevation of BP occurs with other triggers
during the stay, the plan would be recommended
at that time.
* The Interdisciplinary Plans of Care should
be manageable and meaningful for
improved health during this
hospitalization.
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*At change of shift, interdisciplinary rounds,
and handoffs, the Plan of Care Summary
should be reviewed and the prioritizations of
the problems discussed.
* There is no numbering; the documentation
against the progression of the goals and any
addition/discontinuation of goals is evidence of
prioritization.
*This is an active, evolving list of problems to
guide the care of the patient and by addressing
progress, discontinuing, or adding care plans
we are prioritizing what is needed for that
patient at the current time.
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*
*The steps of prioritization are as stated –
initial and continued prioritization based
on active use of the care plans and
documentation of progression
*From a JC standpoint, what is emphasized
is that caregivers can talk about how they
prioritize plans of care for their patients.
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*Our goal has been to ensure
understanding of the care planning
process by all members of the
interdisciplinary team.
*The new optimized IPOC allows us to
create patient-centric plans of care.
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