Created By: Cheryl Simkins, BSN, RN, CCRN Critical Care Clinical Nurse Educator

Full text


Created By: Cheryl Simkins, BSN, RN, CCRN

Critical Care Clinical Nurse Educator



1. Define Professional nursing practice

2. Review the nursing philosophy and Magnet status at UCI.

3. Analyze assessment data to identify priority patient issues.

4. Apply principles of the nursing process to develop a comprehensive care

plan and teaching plan.

5. Develop an individualized care plan and teaching plan utilizing the SBAR

report of a mock patient.

6. Demonstrate knowledge of where to locate patient education materials.

7. Evaluate your mock plan by comparing it to the sample provided.


Nurses felt that POPS/nursing diagnosis did

not drive the care of their patient

Not able to speak to the plan of care

Cumbersome to individualize POPs in the

computer and keep them up to date

Time consuming to print out multiple teaching


want if we changed our


Teaching and care planning documented all in

one place

User friendly and less time consuming

Have daily goals- involving patients and families

in planning care


Professional Nursing Practice



Standards of Practice

Assess, diagnose, identify key issues,

plan, implement and evaluate care based


Standards of Practice

Manage and deliver the care required for

the patient’s condition and individual


Social Policy Statement

Standard Practice Guidelines

Nursing is the protection, promotion, and

optimization of health and abilities,

prevention of illness and injury, alleviation of

suffering through the diagnosis and treatment

of human response, and advocacy in the care

of individuals, families, communities, and


The California Board of Registered Nursing

regulates the practice of registered nursing


Code of Ethics for Nursing

The Code of Ethics for Nurses serves the

following purposes:

It is the profession’s nonnegotiable ethical


It is an expression of nursing’s own


Code of Ethics

Scope and Standards of


State Nurse Practice


Standards of Competent Performance

Nursing Process-encompasses all

significant actions taken by the

nurse and forms the foundation


How do we bring the definition of

nursing, the scope of practice and


Defining Nursing Practice at UC Irvine

The patient & family is

maintained as the

focus of care

Independent nursing

practice is evident and





3 Crucial



Magnet Culture


Magnet designation

at UCI means:

Nursing practice is



autonomy is a main


Focus on decision

making at the


Special thanks to the Critical Care

and Medical surgical Practice


and to the nurses who participated in the care

plan trials


SICU: Janette Sanchez

MICU- Grace Hontucan

BICU- Jen Bauman, Tracy Cueto

NSCU- Sean Sampson, Diana Chairez,

Toks Dada

SSDU- Debbie Blaylock, April

Stubbert, Kim Young Soon,

Dorothy Camarillo

4T- Mae Umali, Ana Lope, Helen

Diamante, Thelma Aquinto

Managers- Victoria Malonzo,

Susanne Collins


Planning of Patient Care


The nurse collects comprehensive, data

pertinent to the patient’s health or situation.

“The RN collects data in a systematic and ongoing


involving the patient and family.”


Nursing Diagnoses/Key issues

Analyzes the assessment data to determine

the diagnoses or issues.

Validates the diagnoses or issues with the

patient, family, and or other healthcare

providers when possible and appropriate.


Outcome Identification/Goal Setting


Provides for continuity of care.

Documents expected outcomes as

measurable and attainable goals.


Goals Interventions

Nursing Interventions:

A nursing intervention is any treatment that a nurse

performs on behalf of a patient to meet the outcomes.



Coordinate implementation of the plan with

the multidisciplinary health care team.

Use health promotion and health teaching




Have the outcomes been met?

When outcomes are not met interventions should

be reassessed for appropriateness in meeting


The patient’s progress or lack of progress toward

goal achievement directs reassessment,

reordering of priorities, new goal setting, and

revision of the plan of nursing care.


A Comprehensive Plan of Care
















What does drive the care of the



Nursing Realms of Practice

1. Independent Function

2. Dependent Function


The majority of the essential nursing functions

are independent nursing functions

Do we give ourselves sufficient recognition for

the independent nursing practice?


How do we communicate our independent

nursing practice?


Documentation provides the evidence that you

provided care

Without documentation no one knows you provided


…What is your contribution?

How did your nursing care

make a difference for the


Is the patient better

because you are here


Is the patient safer?

Did the patient and their

family feel their needs

were met?

Spiritual, Cultural, Physical

How did you make a



teaching will be documented on the

back of the flow sheet.


2. Falls ( PCR- Falls Reduction Program)

Assessment will be done every

shift instead of daily.

Immobile patients are not


Interim Policy

Behavioral Restraint-

restraint that is used for

the management of violent or self-destructive


Medical Restraint-

restraint that is



for violent or self-destructive behavior

Time limited and Indication Based Restraint


Time limited restraint Order

(Medical Restraint)

The patient is demonstrating the behavior specified below, which presents a threat

to his or her welfare and less restrictive means will not be successful in protecting

the patient. Therefore, the following restraint is ordered. This order will remain in

effect until one of the following occurs:

a) The behavior specified is no longer evident or predicted or

b) Less restrictive means are judged to be effective in protecting the patient or

c) The end of the calendar day following the date of this order.

Behavior requiring restraint:


Type of restraint:

Soft belt (chair only)





Enclosure bed


Devices/Disruption of treatment

Less Restrictive means will not be successful in keeping the patient safe,

and the patient meets all three of the following criteria for restraint:


The patient has a tube, line, device or dressing which must remain in place for

essential treatment and which, if accidentally dislodged or contaminated,

would harm the patient.

2. The patient has exhibited behavior or is in a clinical condition that presents the

real danger of accidentally dislodging or contaminating one or more of the

lines, tubes, devices or dressings.

3. The patient is unable to control the behavior which threatens the accidental

dislodging or contamination of tubes/lines/devices/dressings.

Duration: This order shall expire once any of the criteria listed above no

longer exist.


safety awareness

Less Restrictive means will not be successful in keeping the patient

safe, and the patient meets all three of the following criteria for



. The patient has impaired safety awareness or impaired mobility

which increases the risk of falls

2. The patient has exhibited behavior (climbing out of bed or

wandering) that presents the real danger of accidentally injuring


3. The patient is unable to control the behavior which could cause

injury from falls.


self -disruption of skin integrity

Less Restrictive means will not be successful in keeping

the patient safe, and the patient meets both of the

following criteria for restraint:

1. The patient has exhibited behavior (maladaptive

scratching) that presents the real danger of disrupting

the patient’s skin integrity.

2. The patient is unable to control the behavior

which may cause disruption of skin integrity

Duration: This order shall expire once any of


Medical Restraints

Monitoring and assessments shall occur at


Forms no longer needed

Restraint form

Plan of care: Risk for Pressure


Forms we will need

Continue to use Plan of care- Actual

Pressure Ulcer


Changes to the front of the flow sheet

Procedure time out removed

Nutrition supplements


Pain scales

EVD waveform,

Double check







Related subjects :