Prioritizing The Nursing Problem List
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Transcript of Prioritizing The Nursing Problem List
PrioritizingThe Nursing Problem List
Using the Clinical Care Classification- an evidence based Nursing terminology
in the patient’s plan of care
Objectives
1. Describe components of the plan of care
2. State the value of using evidence based care planning terms
3. Understand the CCC Nursing terminology model within HED
4. Develop & Document a usable care plan using CCC problem (Dx) list
VUMC Multi-DisciplinaryPlan of Care
1 Pathway & Phase Sets timed objectives to
meet discharge goals based on predominant medical or surgical plan
2 Provider Plan Orders & planned
procedures
3 Multi-Disciplinary Plans Reflects provider orders Contributes specialty
focus
4 Reflects patient goals
Pathway & Phase
Choose the pathway that most closely reflects the expected patient progression. Usually the reason for admission.
Medical Pathway – Heart Failure Admission – Orders & interventions are aimed at
achieving stabilization ( improving pump action through diuresis, O2, hemodynamic stability, . . .)
Stabilization - achieving a controlled symptoms (fluid excess control, med mgmt
Discharge – Ready for self-care; or care by another caregiver.
Surgical Pathway - Knee Replacement Pre-op Pre; Post-op Stabilization; Discharge
Managing/preventing problems can help reduce length of stay and improve the quality and cost bottom line
Adverse patient effects hospital acquired conditions (infections, injuries) dissatisfaction (unhappy, lost wages) . . .
Adverse VUMC effects lost revenue from under-reimbursed care days losing patients due to having no available beds . . .
- 2 4 6 8
Extended LOS (under-reimbursed)
Expected LOS
Days
Phase
Pathway ProgressionMedical/Surgical Phases
I: Admission/Pre-Op
II: Stabilization/Post-op
Problem: Infection/Fall
III: Discharge
Problem: Discharge Delay
Medical Plan of Care
Multi-D Plan of Care
Nursing Plan of Care
The clinical team implements the medical plan of care (orders)andcontributes its own specialty focus by
Assessment Diagnosis Plan Intervention Outcome evaluation
Plans of Care
Assessment
Standards of Care (SOC*) Physical Assessment (standard met/not met) Past medical/surgical/functional Assessment Baseline vital signs . . . Screening scales: braden, fall, confusion, pain
Population based SOC Scales: Glascow coma, RASS, . . . More frequent and complex targeted
assessment Mosby’s evidenced based guidelines (diabetes
…)
* SOC – care administered without need for orders
Nursing diagnoses = Problem List
Nursing diagnosis is "a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.
Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable" (NANDA, 1992 p. 5). They describe clinical nursing practice in a uniform manner.
Evidence Base
The 182 Clinical Care Classification* (CCC) problems (dx) were derived from 40,361 nursing diagnoses and/or patient problems collected from the research study patients for an entire episode of care as requiring nursing services including the actual outcome on discharge.
Standardizing our clinical terms helps us share patient info across settings and disciplines; allows us to empirically test our interventions and build new evidence to advance the profession
*Developed by Virginia K. Saba, RN , PhD
CCC Frameworkfor the Nursing Plan of Care
21 Categories: Skin Integrity182 Problems (Dx): Oral Mucous Membranes Impairment 3 Expected Outcomes: Improve, Stabilize,
Support decline198 Interventions: Mouth Care4 Actions: Assess, Care, Teach, Manage3 Actual Outcome: Improved, Stabilized, Decline
supported
21 CCC CategoriesPhysiological
Cardiac Bowel/Gastric Life cycle (pregnancy) Metabolic (glucose) Physical Regulation (infection) Respiratory Skin Integrity Tissue Perfusion Urinary
Medication
Psych/Behavioral Cognitive Coping Health Behavior Role Relationship Self Care Self Concept
Functional Activity Fluid Volume Nutrition Safety Sensory/Pain
CCC Problem Coding*59 major & 123 sub-categories
Category (R) Skin Integrity R46 Skin Integrity Alteration Change in or modification of skin
conditions R46.1 Oral Mucous Membranes Impairment R46.2 Skin Integrity Impairment R46.3 Skin Integrity Impairment Risk R46.4 Skin Incision R46.5 Latex Allergy
R47 Peripheral Alteration Change in or modification of vascularization of
the extremities *CCC codes map directly to multi-d concepts (SNOMED) supported by NLM
3 CCC OutcomesExpected/Actual
1. Improve/Improved Condition will change and/or recover (fracture,
pneumonia)
2. Stabilize/Stabilized Underlying Condition will not change but requires no
further nursing care to maintain (asthma, heart failure)
3. Support Decline/Decline Supported Condition will change and worsen (cancer, ESRD).
Nursing action supports decline.
Plan of Care admission documentation____________________Plan of Care Summary________________________Pathway: CHF (chart once) Phase: Admission (update prn)
Nsg Summary: Pt admitted via ambulance in respiratory distress…Plan Priorities: IV diuretics, fluid restrictions, I&O, reduce anxiety….____________________Initial Problem______________________________Priority Problem: Fluid Volume ExcessMay be related to: CHF, fluid intake, hi Na dietExp Outcome: Stabilize______________________q shift plan and outcomes__________________Exp Outcome Detail: diurese .5L this shiftExp Outcome Status: Not Met
Interventions: chart as usual
Activity Problems
Activity AlterationChange in or modification of energy used by the body
Activity IntoleranceIncapacity to carry out physiological or psychological daily
activities
Activity Intolerance RiskIncreased chance of an incapacity to carry out physiological or
psychological daily activities
Activity IndifferenceLack of interest or engagement in leisure activities
FatigueExhaustion that interferes with physical and mental activities
Mobility ImpairmentDiminished ability to perform independent movement
Sleep Pattern AlterationImbalance in the normal sleep/wake cycle
Sleep DeprivedLack of the normal sleep / wake cycle
MuscSkeletal AltChange in or modification of the muscles, bones or support
structures
Alt = Alteration
Physical Regulati
on
Physical Reg-OthChange in or modification of somatic control
HyperreflexiaLife threatening inhibited sympathetic response to a noxious stimuli in a person with a spinal cord injury at T7 or above
HyperthermiaAbnormal high body temperature
HypothermiaAbnormal low body temperature
Thermoregulatory ImpairmentFluctuation of temperature between hypothermia and hyperthermia
Infection RiskIncreased change of contamination with disease-producing germs
Infection
Contamination with disease-producing germs
IntrCranialFluid Intracranial fluid volumes are compromised
Prioritizing Problems
Patients have many problems, what makes it a priority problem?
When it Is the patient’s priority (pain, SOB, anxiety) Keeps the patient from moving to the next phase (fluid
volume excess) High probability for harm (infection risk, falls) Delays discharge
Note that Day & Night shift may have different priorities (ambulation vs. sleep)
Choosing the best problem descriptor
Choose the problem that most closely aligns with the interventions that you will do for this phase.
My pt has Heart Failure – which problem do I pick?
If you are focusing on fluid mgmt (IV diuretics, I&O, lo Na diet, fluid restriction) pick Fluid Volume Excess
If you are focusing on breathing treatments, choose Respiratory Alteration
-------Neither are wrong – both may be selected -------
Maintaining a short - usable Problem list
Initiate problems thoughtfully & miserly – do not replicate standards of care unless they are a priority problem that you are actively monitoring or treating.
Where possible, maintain the problems that have been started by the previous nurse until there has been significant progress towards goals or the problem has been resolved. Do not change for a slightly better descriptor.
Not all problems need be addressed every shift – day and night shift will have different priorities
Use the HED significance flag ! Plan Priorities reflects priorities for the next 12 hr.
Plan of Care ReportAvailable now in Standard HED format(many pages – not well formatted)
Use as Backup When paper is requiredi.e. Transfer to another facility
August 2010:
A 1-2 page plan of care summary will be available.
Goal – create a paper plan of care that can be used in bedside report and given to the patient and family.
Phase II - CCC Interventions
ExampleSkin IntegrityWound CareModifiers:1. Assess wound care2. Perform wound care3. Teach wound care4. Manage wound care (consult)
Future: HED documentation will be mapped to the action types
RESPIRATORY CARE COMPONENT
(1) Assess Breath Sounds
RUL RLL LUL LLL
SOB etc.
(2) Perform Oxygen Therapy Care Breathing Exercises Chest PT Inhalation Ventilator Care Trach Care
(3) Manage/Refer/Notify(4) Teach
Phase III – Reports & Views
1. Printed Plan of Care to share with the patient and/or upload to MyHealth@V
2. Visualizing the problem list through Dashboards•Staff Nurse View•Unit Manager View•Exec/Admin Views
Graphical Display of Priority Problems
Staff Nurse View cues to:
#1 CHF : Monitor cardiac, perfusion, fluid balance, resp#2 Diabetic: Monitor glucose, diet, and skin#3 CABG: Ambulate CABG & protect from falls#4 Unknown: Diarrhea, fever, hypercapneic
Problems key: Priority Resolving Resolved
Graphical Display of Priority Problems
Charge Nurse ViewEntire unitPossible C-Diff outbreak
Graphical Display of Priority Problems
Exec ViewEntire HospitalHighlights Discharge ConcernsOrOpportunitiesFor targeted education & surveillance
Spread the word
Look for opportunities to use the CCC terms framework in your current work.
Plan of Care Exercise
Think about a recent patient and review their pathway
•Fracture•Burn•Asthma•COPD
Check of 3-5 high priority problems from the handout
Refer to Mosby’s evidence based plans of care if needed