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

August 16, 2010 Created By: Cheryl Simkins, BSN, RN, CCRN Critical Care Clinical Nurse Educator 1

August 16, 2010 Objectives: 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. 2

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 plans 3

Nurses Surveyed- what did nurses want if we changed our documentation 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 Meaningful EP7EOf, Internal Consultant's Education PowerPoint Module-Documenting Teaching and Plan of Care.pdf 4

Professional Nursing Practice What is our Professional Responsibility? 5

Essential Standards of Practice Assess, diagnose, identify key issues, plan, implement and evaluate care based on the patient and family needs 6

Essential Standards of Practice Manage and deliver the care required for the patient s condition and individual human response 7

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 populations. 8

State Nurse Practice Art The California Board of Registered Nursing regulates the practice of registered nursing and certified advanced practice nurses 9

Code of Ethics for Nursing The Code of Ethics for Nurses serves the following purposes: It is the profession s nonnegotiable ethical standard It is an expression of nursing s own understanding of its commitment to society. 10

Definition of Nursing Scope and Standards of Practice State Nurse Practice Act Code of Ethics Standards of Competent Performance Nursing Process-encompasses all significant actions taken by the nurse and forms the foundation of the nurse s decision making Planning Patient Care 11

How do we bring the definition of nursing, the scope of practice and ethics to life at UCI? 12

Defining Nursing Practice at UC Irvine Nursing Philosophy + 3 Crucial Relationships + Magnet Culture The patient & family is maintained as the focus of care Independent nursing practice is evident and embraced 13

Nursing practice at UCI 14

Magnet designation at UCI means: Nursing practice is supported Professional autonomy is a main focus Focus on decision making at the bedside Special thanks to the Critical Care and Medical surgical Practice Councils 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 All the nurses and managers who gave their input. 15

Planning of Patient Care Assessment: The nurse collects comprehensive, data pertinent to the patient s health or situation. The RN collects data in a systematic and ongoing process involving the patient and family. 16

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. 17

Outcome Identification/Goal Setting Individualized Provides for continuity of care. Documents expected outcomes as measurable and attainable goals. 18

Goals Interventions Nursing Interventions: A nursing intervention is any treatment that a nurse performs on behalf of a patient to meet the outcomes. 19

Implementation Coordinate implementation of the plan with the multidisciplinary health care team. Use health promotion and health teaching methods. 20

Evaluation Have the outcomes been met? When outcomes are not met interventions should be reassessed for appropriateness in meeting outcomes 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. 21

A Comprehensive Plan of Care Assessment Diagnosis Outcome identification Planning Implementation Evaluation Evaluation Assessment Implementation Planning Diagnosis Outcome Identification 22

What does drive the care of the patient? 23

Nursing Realms of Practice 1. Independent Function 2. Dependent Function 3. Interdependent Function 24

The majority of the essential nursing functions are independent nursing functions Do we give ourselves sufficient recognition for the independent nursing practice? 25

How do we communicate our independent nursing practice? DOCUMENT, DOCUMENT, DOCUMENT Documentation provides the evidence that you provided care Without documentation no one knows you provided the care for the patient Without documentation you DID NOT provide the care 26

Important Questions to ask yourself What is your contribution? How did your nursing care make a difference for the patient? Is the patient better because you are here today? Is the patient safer? Did the patient and their family feel their needs were met? Spiritual, Cultural, Physical How did you make a difference? EP7EOf, Internal Consultant's Education PowerPoint Module-Documenting Teaching and Plan of Care.pdf 27

FUNCTIONAL STANDARD of CARE: Nursing Diagnoses, Outcomes, and Interventions Nursing Diagnoses EP7EOf, Internal Consultant's Education PowerPoint Module-Documenting Teaching and Plan of Care.pdf Definition Outcomes Interventions 28

All the care planning and most of the teaching will be documented on the back of the flow sheet. 33

Change in Fall Policy 2. Falls ( PCR- Falls Reduction Program) Assessment will be done every shift instead of daily. Immobile patients are not considered at risk for falls. 34

Change in Restraint Policy Interim Policy Behavioral Restraint- restraint that is used for the management of violent or self-destructive behavior Medical Restraint- restraint that is not used for violent or self-destructive behavior Time limited and Indication Based Restraint orders 35

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) Vest Mittens RUE LUE Enclosure bed Soft limb restraint RUE LUE RLE LLE 36

Restraint order for patients with Invasive 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: 1. 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. 37

Restraint order for patients with impaired 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 restraint: 1. 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 themselves. 3. The patient is unable to control the behavior which could cause injury from falls. EP7EOf, Internal Consultant's Education PowerPoint Module-Documenting Teaching and Plan of Care.pdf Duration: This order shall expire once any of the criteria listed above no longer exist. 38

Restraint order for patients with risk for 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 the criteria listed above no longer exist 39

Medical Restraints Monitoring and assessments shall occur at least every 2 hours. 40

Forms no longer needed Restraint form Plan of care: Risk for Pressure Ulcer 41

Forms we will need Continue to use Plan of care- Actual Pressure Ulcer Cardiac Rhythm strips 42

Changes to the front of the flow sheet Procedure time out removed Nutrition supplements QTc Pain scales EVD waveform, Double check ETCo2 Braden scale-definitions removed from back of flow sheet 45

Navigating through Patient Education Materials 59

Questions? 76