Section 1 The Nursing Process

Upon completion of Section 2.1, you will be able to:

 Discuss the five stages of the nursing process as evidenced by correctly selecting the corresponding answers in the Unit one Review Questions

 List five North American Nursing Diagnoses Association (NANDA) diagnosis that would be suitable to include in a care plan

What is the Nursing Process and how does it relates to the Nursing Care Plan?

The nursing care plan records the nursing process (Wang, Yu, & Hailey, 2015). In following the steps of the nursing process, the RN is able to more effectively identify goals for the resident that will assist in achieving the desired outcomes.

After years of refinement, the nursing process evolved into a five step process: Assessment, Nursing Diagnosis, Planning, Implementation, and Evaluation.

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Steps, Definitions, and Descriptions of the Nursing Process

The information below lists all of the steps, definitions, and description of the nursing process. It is important to understand this information before care plan development begins.

 In conducting the assessment, the focus should include the psychological, spiritual, functional, sociocultural, economic, and lifestyle abilities of the resident, as well as physician findings, and diagnostic studies.

 Nursing diagnoses provide the foundation upon which nursing interventions are developed. Based on the NANDA, common examples include:

o Activity Intolerance, risk for o Communication, impaired verbal o Coping, ineffective

o Injury, risk for

o Self-care Deficit, bathing o Urinary Elimination, impaired

 For problems considered curable, or temporary, goals and interventions should relate to resolving or improving within the next target date review period.

 For problems not anticipated to improve significantly, the goal should consider how the problem can be kept from deteriorating any further.

 For problems that will not get any better, the goal should reflect how to provide an optimal quality of life and comfort to the resident (CRNNS, 2017). Assessment is the “systematic collection of data relating to clients, their problems, and

needs” Doenges, et al., 2010, p. 7

Nursing diagnosis is “a clinical judgment about an individual, a family, or a community’s response to actual and potential health problems or life processes”

Muller-Staub, Lavin, Needham, & van Achterberg, 2006, p. 516

Planning is where the needs of the individual are prioritized, goals are identified, and interventions are chosen by the RN in conjunction with the resident, whenever possible

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 The interventions are specific to each resident and focuses on achievable outcomes  Includes monitoring the resident, directly caring for the resident or performing tasks,

educating and instructing the resident, and possibly referring the resident to other care providers in the multidisciplinary team (Doenges et al., 2010)

 A review should be conducted, at minimum, every three months in LTC to assess: o If goals have been achieved

o To determine barriers to progress

o To evaluate suitability or quality of care provided o To reassess current needs based on progress o To revise the care plan if necessary

o To set the date for the next review

(Ballantyne, 2016; CRNNS, 2017) Implementation is the act of carrying out any treatment identified in the planning

phase. Doenges et al., 2010

Evaluation occurs once all nursing intervention actions have taken place; the nurse completes an evaluation to determine if the goals for patient care have been met

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-The CP is a fundamental component of nursing practice that aims to facilitate standardized, evidence-based holistic care.

-The overall goal of care is to ensure continuity and quality of care, while providing safe environments for residents.

- Electronic CPs enables the RN to record care that has been provided. They allow for that information to be shared with other health disciplines in a quick, efficient manner. CPs are also used as a guide to reassess the effects of care on residents needs

(Doenges et al., 2010; Ballantyne, 2016) Unit 2: Section 2

The Nursing Care Plan Upon completing Unit 2.2, you will be able to:

 Explain the goal of care planning in achieving resident outcomes

 Describe why developing a care plan is important in providing resident care

 List examples of nursing interventions that can be added to the resident’s plan of care  Compare and contrast the strengths and limitations of the nursing care plan

The Care Plan

Types of Care Needs Identified through Care Plan Development

Through the development of the care plan, the RN can determine aspects of resident care needs. Examples of types of care identified based on care plan development and

implementation include:

*Bathing & Dressing *Behavior Status *Wound Care *Oral Care *Skin Care *Hair Care *Nail & Foot care *Eating habits *Vital Sign Monitor *Mobility & Activity *Transferring *Incontinence Care *Hearing & Speech *Vision Capabilities *Sleep Pattern *Bladder/Bowel status *Fall Risk *Language Issues *Food Preference *Mental Status

129 Benefits of Electronic Care Planning

There are several benefits to developing a nursing care plan:

 Care plans provide a comprehensive record. The record links resident problems, goals, and interventions to related policies, procedures, and guidelines of the organization

 Aids in record keeping. Provides cues and prompts for the nurse and facilitates the documentation of assessment, patient care, communication, and teaching

 Provides direction to staff. Standardized CPs provide direction in relation to the interventions that are needed to best meet the residents specific needs

 Permits detailed auditing. Chart audits can be completed at any time from any location

 Version control is decreased. NANDA guidelines gives more control on diagnosis labels used in the care planning process

 Statistics are readily available. Electronic charts can more easily be subjected to statistical analysis by the Canadian Institute for Health Information (CIHI)

(Lee, 2005; Mills, 2005; Smith, Smith, Krugman, & Owen, 2005; Muller-Staub et al., 2006; Keenan et al., 2008;Ballantyne, 2016)

Limitations of Electronic Care Planning

Although there are several benefits to electronic care planning, some limitations also exist:  RNs have expressed that there is a lack of time, staff, education, and resources to

commit to the care plan process and electronic documentation

 Another limitation is the requirement to update the care plan on a continuous basis, especially as care needs change

 There are concerns that standardized care plans populate more interventions than what are actually required for the resident

 RNs have questioned the effectiveness, relevance, and clarity of care plans in relation to co-morbidities. (Lee, 2005; Cherry et al., 2008; Department of Health, 2012)

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Unit 2: Section 3