1. Safe and appropriate for client's age, health, and condition 2. Achievable with available resources 3. Be congruent with other therapies and with client's values, beliefs, and culture 4. Be knowledge based
What intervention parameters are used for actual nursing diagnosis?
Reduce or eliminate contributing factors/diagnosis, promote higher level of wellness, monitor status
What intervention parameters are used for risk nursing diagnosis?
Reduce or eliminate risk factors, prevent the problem, monitor for onset
What intervention parameters are used for health promotion diagnosis?
Extend the client's skill, performance or achievement beyond current level
What legal parameters should be kept in mind when selecting nursing interventions?
They should be within established standards of care as determined by state laws, professional and accrediting organizations, and the policies of the institution
What are the purposes of a nursing care plan?
1. Promote communication 2. Direct care 3. Create a record that can later be used for evaluation, research, legal, and insurance purposes
What is an informal nursing care plan?
A strategy for action that exists in the nurse's mind
What is a formal nursing care plan?
A written guide that organizes information about the client's care
What is a standardized care plan?
A formal plan that specifies the nursing care for groups of client's with common needs (e.g. all clients with diabetes), are part of the client's record
What is an individual care plan?
A formal plan that is tailored to meet the unique needs of the client
How does a Student Care plan differ from Nursing Care plan?
Student care plan may include rationale and/or concept mapping
What guidelines should be used when writing a nursing care plan?
1. Date/sign 2. Category headings 3. Standardized medical symbols and key words 4. Specificity 5. Refer to procedure books or pre-written when available 6. Tailor to patient 7. Incorporate preventive, restorative, and maintenance measures 8. Ongoing assessment 9. Include collaborative/coordinated activities 10. Include discharge/home health needs
What are JCAHO standards for care plans?
1. Developed by an RN 2. Documented in the client's health record 3. Reflect the standards of care for institution/profession 4. Requires that computer systems are used to asses outcomes
What are CMS standards for care plans?
1. Plan is client centered 2. Is a step by step process 3. Medicare and Medicaid have specific requirements for nurse care plans
What is the purpose of Nursing Intervention Classification (NIC)?
to provide a taxonomy that can help to standardize nursing interventions
What does the NIC consist of?
3 levels (domains, classes, and interventions) which helps to assist in planning and reimbursement, and facilitates clinical decision making
How does the NIC help the field of nursing?
It enhances communication, helps with research, demonstrates the impact of nurses, promotes nursing as a profession
What is the purpose of Nursing Outcomes Classification (NOC)?
describes client outcomes that respond to nursing interventions
How are NOC outcomes designated?
Each outcome belongs to 7 domains and to one class within that domain
How does the NOC help the field of nursing?
By stating outcomes as broad and conceptual that exist on a continuum (different from goals that can be met or not met)
1. Describe routine care that will meet basic needs 2. Address the patient's nursing diagnosis and collaborative problems 3. Specify the nursing responsibilities that will be used to carry out the medical plan of care
What is a collaborative care plan?
standardized plan that outlines the care required for clients with common, predictable (usually medical) conditions, sequences the care that must be given on each day (can include nursing diagnosis in conjunction with medical diagnosis)
What are standards of care?
Usually determined by an institution, defines the nursing actions/interventions that are appropriate for certain medical conditions, they are part of the institution's record rather than client's
What is discharge planning?
the process of anticipating and planning for client needs after discharge. Is a crucial part of comprehensive health care plan and should be addressed in each client's care plan
What are other names for a collaborative care plan
multidisciplinary care plan or critical pathways
Do collaborative care plans only include nursing interventions or doctors orders?
No, they may also include other disciplines (e.g. physical therapy, respiratory therapy)
How does protocol differ from policies & procedures?
Protocol describes actions that are required for a specific group of patients, Policies describe actions to be taken during a frequently occurring situation