Nursing care plan ppt final draft

1. Nursing Care Plan By Beverly Wade

2. Welcome to Careplan Work shop You too can survive nursing school!!!!!!!!!!!!!!!!! "http :// www.youtube.com/embed/PgvVTXhHz58

3. Menu 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

4. What is a Nursing Care Plan 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.

5. What is a Nursing Care Plan 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

6. Types of Nursing Care Plans Actual —What is actually wrong with the patient. Psychosocial - Nursing Process and Self‐Concept Related NANDA Nursing Diagnoses • Ineffective Role Performance • Body Image Disturbance • Chronic low self‐esteem • Self‐esteem disturbance • Situational low self‐esteem • Personal Identity disturbance

7. Psychosocial- Nursing Process and Self‐Concept Related NANDA Nursing Diagnoses • Ineffective Role Performance • Body Image Disturbance • Chronic low self‐esteem • Self‐esteem disturbance • Situational low self‐esteem • Personal Identity disturbance

8. Risk 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

9. NANDA-1 North American Nursing Diagnosis Organization- International Nursing diagnosis Goals for patient and family Nursing care Nursing scientific rational Evaluation

10. How to Write a Care Plan (and not go crazy) 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

11. Data collection Subjective-This is what your patient tells you. “ My head hurts” States on scale of 1-10 My head hurts at 8. Objective- This is what you see. Patient rubbing head.

12. TALK TO YOUR PATIENT This helps you decide what is really wrong with your patient. You must listen to know what they are not telling you.

13. BMP Na L124 136-145 mEq /L K H5.8 3.5-5.1 mEq /L CO2 25 23-29 mEq /L Cl 101 98-107 mEq /L Glucose H107 74-100 mg/ dL Ca 10.1 8.6-10.2 mg/ dL BUN 17 8-23 mg/ dL Creatinine 0.9 0.8-1.3 mg/ dL Key: L=Abnormal Low, H=Abnormal High, WNL=Within Normal Limits, *=critical value -------------------------------------------------------------------------------- Specimen(s) Collected: 2/10/08 14:30 Lab Acc'n No. 223457 Specimen: Blood Date Reported: 2/10/08 15:30 Test Name Patient's Results Ref. Range Units HGB L7.0* 14.0-18.0 gm / dL HCT 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. Doe Date Reported: 2/10/08 18:40 HGB A1c

14. Nursing Diagnosis 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. It must be individualized for your patient

15. A 3 Part System 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

16. Patient Goals 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

17. How to write goals Must be : Patient centered Clear and concise Observable and measurable time limited Realistic one behavior /goal determined by patient, family, nurse together.

18. Measurable and non-Measurable Verbs measurable Non -measurable Identify Describe Perform Relate State List Verbalize Demonstrate Share Express Communicate Exercise Cough Walk Stand Sit Discuss Has an increase in Has a decrease in Has an absence of Know Understand Appreciate Think Accept Feel

19. Nursing Interventions 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=xRFIDg9BPnQ Example: If you study hard then you will graduate

20. Nursing Rational 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.

21. What makes a Failing Student

22. Evaluation 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.

23. EYEBALL SHEET EYEBALL SHEET

24. Care Plan paper work We have covered every aspect of this paper

25. Daily work This is the form you will turn in daily and it will help you write your care plan

26. Clinical Evaluation Sheets This form will be given to you on Friday after clinical. If your instructor is very busy, you will receive it on Monday.

27. You tube video on Care Plans http:// www.youtube.com/watch?v=onnoPvwJ8SM&feature=plcp

28. Review questions 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

29. Now it is Your Turn

30. Example Care Plan Practice 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 severe crushing chest pain unrelieved by rest which has lasted for 2 hours. The pain is substernal and does not radiate. He states the pain is a 9 on 0-10 pain scale. He says he smokes 2 packs of cigarettes per day, is a manager at an electronics firm, and that his father died @age 59 of a heart attack

31. Continued Data 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.

32. http ://www.youtube.com/watch?v=fU0f5bgbj0s&feature=related

33. Light bulbs? http:// www.youtube.com/watch?v=gBzJGckMYO4

34. Resources DeWitt, S. (9 th ed ), Medical- Surgical Nursing Concepts and Practice, St. Louis, Mo., Saunders PowerPoint's. http:// emievil.hubpages.com/hub/7-Bad-Study-Habits-A-College-Student-Must-Not-Have Microsoft clip art and microsoft office Case studies from previous classes and patient files.