FUNDA LEC

• Plan of care


  A plan developed by the nurse that prescribes interventions to attain expected outcomes

  
• 4 Main Purposes of the Plan of Care

  • Promotes communication among caregivers to promote continuity of care
  • Directs care and documentation
  • Creates a record that can later be used for evaluation, research & legal reasons
  • Provides documentation of health care needs for insurance reimbursement purposes
• Activities of the PLANNING PHASE

  1. Attending to urgent priorities

  2. Clarifying expected outcomes

  3. Deciding which problems must be prescribed

  4. Determining Individualized Nursing interventions

  5. Making sure the plan is adequately recorded

  
• BASIC PRINCIPLES: ATTENDING TO URGENT PRIORITIES

  • Choose a method of assigning priorities and use it consistently
  • Maslow's Hierarchy of Needs
• Problems usually present in a cluster – study the relationships among the problems to determine major priorities
• Assign high priority to problems that contribute to other problems
• Guidelines for Setting Priorities

  • Maslow's hierarchy of basic needs can guide the selection of high-priority problems
  • Focus on the problems the patient feels are most important if this priority does not interfere with medical treatment
  • Consider the patient's culture, values and beliefs when setting priorities
  • Consider the effect of potential problems when setting priorities
  • Consider costs, resources available, personnel and time needed to plan & treat each of the patient's identified problems
  • Consider state laws, hospital policy statements, and outcome criteria established for the particular setting
• Patient Outcome


  The desired result of nursing care; that which one hopes to achieve with the patient and which is designed to prevent, remedy or lessen the problem identified in the nursing diagnosis

  
• Outcome Identification


  The nurse identifies expected outcomes individualized to the patient
• The nurse develops outcomes for the patient to achieve showing an optimum or improved level of functioning in the problem areas identified in the nursing diagnoses
• Goals & Objectives


  Refers to the intent, what you intend to do
• Outcomes


  Refers to results, what you expect the patient to be able to do
• 3 Main Purposes of Outcomes

  • They are the "measuring sticks" for the plan of care
  • They direct interventions
  • They are motivating factors
• Principle of Patient-Centered Outcomes


  • Outcome describe the specific benefits you expect to see in the patient after care has been given
  • Outcome may relate to problems or interventions
  • To create explicit outcomes, include the following components: subject, verb, condition, performance criteria, target time
• Patient Behavior


  An observable activity the patient will demonstrate at some time in the future showing improvement in the problem area
• Conditions


  Specific aids that will help the patient perform a behavior at the level specified in the criteria portion of the outcome statement
• Performance Criteria

  A stated level or standard for the patient behavior stated in the outcome
• Time Frame


  A time or date to clarify how long it would realistically take for the patient to reach the level of functioning stated in the criteria part of the outcome
• Types of Time Frames

  • Intermediate Outcomes
  • Long Term or Final Outcomes
  • Discharge Outcomes
  • Health Promotion/Wellness Outcomes
• At a basic level, determining outcomes requires you to simply "reverse the problem", or state what you expect to observe in the patient after you perform an intervention
• Guidelines for Writing Outcome Statements or Objectives

  • For an actual nursing diagnosis, the outcome is a patient behavior that demonstrates reduction or alleviation of the problem
  • For at risk nursing diagnosis, the outcome is a patient behavior that demonstrates maintenance of the current status of health or functioning
  • The outcome is realistic for the patient's capabilities in the time span you designate
  • The outcome is realistic for the nurse's level of skill, experience and time/workload
  • The outcome is congruent with and supportive of other therapies
  • Whenever possible, the outcome is important and valued by the patient, family, the nurse and the physician
  • The outcome is an observable or measurable patient behavior
  • Write outcomes in terms of patient behavior, not nursing actions
  • Keep the outcome short
  • Make the outcome specific
  • Derive each outcome from only one nursing diagnosis
  • Designate a specific time for the achievement of each outcome

  
• 3 Basic Steps To Determining Which Problems Must Be Recorded

  1. Create a problem list

  2. Decide which problem must be managed in order to achieve the overall outcomes of care

  3. Determine what documentation will guide how each problem will be managed
• It's your responsibility to make sure that any problems, diagnoses, risk factors that are likely to impede progress toward outcome achievement are addressed somewhere on the patient record