Nursing Care PlanIntroduction : Nursing Care PlanIntroduction Robscpne.com
Welcome / How things work : Welcome / How things work Can everyone hear me? If not:
Turn on / up your speakers -
Don’t worry, most of what I say from these classes will be uploaded to www.robscpne.com for easy viewing later
Let’s take a look at some of the options in this online class….
webcam
raise hand / cancel
text box (need to test – do we need to raise hand ?)
whiteboard
Welcome / How things work (cont) : Welcome / How things work (cont) I am not THE expert
Some things I will be learning from YOU
CPNE vs. real life NCP’s – This session will only go over the BASICS of NCP’s. Excelsior has their own rules for NCP’s which we will go over in the next class
Timeline of events : Timeline of events 8:05 - Parts of the Care Plan (ND + R/T + AEB)
8:20 - picking the correct "Projected Measureable Pt outcome for diagnostic label" (i.e. pt. goals/outcomes)
8:35 - Choosing appropriate "Nursing interventions which will move pt toward achievement of the expected outcome" (i.e. nursing interventions)
8:50 – Questions and homework assignment
Eval NCP – Pg. 92 (everyone) – 8:05 : Eval NCP – Pg. 92 (everyone) – 8:05
Nursing diagnostic label (ND + R/T + AEB) : Nursing diagnostic label (ND + R/T + AEB) ND (nursing diagnosis) + R/T (related to) + AEB (as evidenced by)
We need an example – go to pg. 168 in Mosby’s Guide to Nursing diagnosis book
On pg. 168 we see the diagnosis of:
ACTIVITY INTOLERANCE
Nursing diagnostic label (ND + R/T + AEB) : Nursing diagnostic label (ND + R/T + AEB) Now that we have the nursing diagnosis (ND) we need the related to part next --(R/T)
(There are 6 choices here, choose the one that fits your patient)
For this example let’s pick the first one : BED REST
So now we have : Activity Intolerance related to Bed Rest ----We now have 2 of the 3 ! Only one more to go !
IMPORTANT: pg. 475 in the CPNE guidebook states that you CAN use medical diagnosis in your R/T section. (secondary to ??)
Nursing diagnostic label (ND + R/T + AEB) : Nursing diagnostic label (ND + R/T + AEB) Activity Intolerance R/T bed rest AEB______
Let’s take a look at pg. 168 again - (Defining characteristics section)
The “DEFINING CHARACTERISTICS” section is your AEB part
For this example let’s use: verbal report of weakness
So then, our Nursing diagnostic label would be:
Activity Intolerance related to Bed Rest as evidenced by verbal report of weakness.
Nursing diagnostic label (ND + R/T + AEB) : Nursing diagnostic label (ND + R/T + AEB) So we have our COMPLETE nursing diagnostic label, But WAIT !
You don’t need the R/T or AEB section in the PLANNING phase !
pg. 475 it states that “ONLY Part 1 of a 2 or 3 part nursing diagnostic statement will be scored, as such the R/T and AEB is just a waste of time !! (you will need to know how to do this later)
Projected Measurable expected patient outcome - 8:20 : Projected Measurable expected patient outcome - 8:20
Projected Measurable expected patient outcome : Projected Measurable expected patient outcome "Nursing interventions which will move pt toward achievement of the expected outcome" is a VERY long way to say “pt goals”
What is the goal for the patient during YOUR PCS ?
This will be expressed as "THE PT WILL“ so, let’s look at pg. 168 again under CLIENT OUTCOMES / CLIENT WILL (Specify time frame)
For this example, let’s try: The pt. will: Demonstrate increased tolerance to activity. (There are 5 options here, pick the one that you think the pt. would probably be able to obtain/do)
IMPORTANT: On pg. 87 of the CPNE guidebook it states - to try to use your own words for "pt outcomes“ – How could we do this ?
Nursing interventions which will move pt toward achievement of the expected outcome – 8:35 : Nursing interventions which will move pt toward achievement of the expected outcome – 8:35
Nursing interventions which will move pt toward achievement of the expected outcome : Nursing interventions which will move pt toward achievement of the expected outcome Nursing interventions which will move pt toward achievement of the expected outcome is a VERY long way to say Nursing Interventions
Let’s look at pg. 168 again under NURSING INTERVENTIONS.
to get the pt to achieve his goal of "DEMONSTRATE INCREASED TOLERANCE TO ACTIVIITY" we could:
1) when getting a client up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs. (ASSESSMENT)
2) Work with the client to set mutual goals that increase activity levels (INTERVENTION)
Nursing interventions which will move pt toward achievement of the expected outcome : Nursing interventions which will move pt toward achievement of the expected outcome IMPORTANT: pg. 89 of the CPNE guidebook (second bullet) states to use your own words for NI‘s
HOWEVER, if those nursing interventions and pt outcomes directly relate to your patient then you should be fine.
How could we use our OWN wording for the SECOND nursing intervention of:
2) Work with the client to set mutual goals that increase activity levels
(volunteers)
Questions and homework (time permitting) : Questions and homework (time permitting) Questions first….
On to homework assignment – (time ?)
Case example: Pt has:
abdominal incision
Rating of pain of 6 on a scale of 1-10
Unbalanced gait when ambulating
Only ate 25% of breakfast tray
Has not had a BM x 48 hours, usually goes QD
if no time E-mail via www.robscpne.com (optional)