Care Planning Flashcards
what are the steps in the nursing process?
1. Assess
- Plan
- Implement
- Evaluate
what information should the nurse gather on admission/assessing a patient for each category?
Essential Information Clinical aspects Disease Medications and drug history Social and Family History General Specific/sensory Gender related Baseline obs Patient specific obs
Essential Information: Name, Address, DOB, telephone number, emergency contact details, GP and other health professionals (DNs, Specialist Nurses, OT/Physiotherapy)
Clinical aspects: Past Medical History: major illnesses, injuries and previous operations, current and past medical conditions
Disease- What is the reason for referral or admission?
Medications/drug history: All prescribed and over the counter medication (including contraceptives); Illegal or non-prescribed drugs; herbal/complementary therapies and allergies.
Social and family history: marital status, children, occupation, background, language, religious beliefs and any specific cultural/ethnic requirements
General: alcohol consumption, tobacco consumption, dietary preferences, food allergies, bowel habits, urinary frequency, general mobility issues
Specific: sight – do they wear glasses? Hearing – do they have hearing aids? Taste – any dentures or bridges? Assess oral mucosa. Skin – any problems – ulcers, excoriation, wounds?
Gender related: Males – any prostate or testicular problems? Females – last menstrual period (LMP)? Breast lumps/obstetric history
Baseline observations: Blood Pressure, Pulse, Respirations, Temperature, Weight, BMI, Height, Urinalysis
Patient specific observations: Blood sugar, Peak Expiratory Flow Rate (PEFR).
what is care planning and why is it important
- Linchpin of good quality care
- Identify & set realistic goals
- Identify priorities of care
- Recording the care plan
what is think SMART?
SPECIFIC in terms of problem
MEAUSURABLE how do you measure care?
ACHIEVABLE is the care planned achievable in the time frame?
REALISTIC can they be achieved?
TIME ORIENTATED how long will the patient be admitted?
what is the role of the nurse in planning care
- Solve existing, presenting problems
- Prevent identified potential problems from becoming actual problems
- Alleviating problems that cannot be solved and assisting the individual to cope positively with these problems
- Preventing recurrence of a treated problem
- NMC Essential Skills Clusters: compassion and communication
- Ensure evidence based knowledge underpins assessment
- Standards for Records and Record Keeping.
what is involved in implementation (general description)
- Nursing actions
- Nursing interventions
- Observing, measuring, listening, talking/reassuring
what is involved in evaluation (general description)
- Determine the progress towards achieving the goals
- Reassess the patient to determine whether or not the goals have been met.
why in input from the patient essential
encourage compliance
furthers patient understanding and education
increase autonomy
moves away from medical model where patient has little to no input in their own care plan
avoids patient having unrealistic expectations (follows SMART criteria)
helps prioritise care
at what stage of the therapeutic relationship does care planning occur
will begin from the first patient contact and continue until the nurse-patient relationship ends
how do care plans prioritise care and increase patient education? (hint: examples!!)
the nurse and patient will not always agree on priorities e.g completing a treatment vs going home, so these should be openly discussed. this can also involve patient education, e.g. an elderly patient may not want to reposition in bed and would rather be ;eft alone, but the nurse will have knowledge of risk of pressure damage and must inform and work wit the patient to carry out these necessary interventions
