SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE

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1 SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE Subject: GUIDELINES FOR USE OF THE No. NURSE-17 INTERDISCIPLINARY PLAN OF CARE Page 1 of 5 Prepared by:dianne Woods, RN Original Issue Date: 12/09 Committee Nursing Clinical Practice Council Supersedes: NEW Approved: Effective Date: 11/13 Approved by: Margaret Jackson, MA, RN Miriam T. Vincent, M.D., PhD, JD TJC Standards: PC CMS Tag # (b)(4) Michael Lucchesi, M.D. William Holman, M PH Issued by Regulatory Affairs I. PURPOSE: 1. To communicate the patient s present health status and current needs to all members of the healthcare team involved in providing care. 2. To identify problems solved and those yet to be solved, providing information about approaches that have been successful. The care plan documents the patient s situation at the present time and should reflect changes as they occur in the patient s condition. a. For example a patient undergoing cardiac surgery may have the following immediate post op problems Pain Decreased Cardiac Output, Risk of infection b. After a few days, when these issues are resolved, the patient s needs may shift to Learning need (diet, medications) Improving activity tolerance for ADL s A-I Definition of Nursing Diagnosis 3. To enable clear, concise documentation of a patients health diagnoses, individualized, patient specific goals, interventions, and outcomes planned by nursing personnel or other disciplines II. POLICY The Nursing Department will develops and maintain current nursing care plan for each patient based on the initial patient assessment. Care plans will be reviewed and updated regularly as patient condition changes. The nursing care plan is developed in

2 GUIDELINES FOR USE OF THE INTERFDISCIPLINARY PLAN OF CARE conjunction with the medical plan of care and integrated with other disciplines. The plan of care is a permanent part of the medical record and is documented on the Interdisciplinary Plan of Care form. III. DEFINITIONS 1. Problem/ diagnosis - A diagnosis is a clinical judgment about a patient s individual responses to actual or potential health problems. It is the basis for selection of interventions to achieve outcomes. 2. Short term goals Outcomes that should be achieved usually within the first few days of admission. This will vary with each patient. Goals should a. Be specific b. Be realistic or achievable c. Be measurable d. Indicate a definite time frame for achievement e. Consider client s desires and resources f. Examples (for hypertension) BP will be within normal limits (for pain) Pain will be relieved/controlled within 1 hour of analgesic administration (for diabetes) Patient will verbalize basic understanding of disease process 3. Long term (discharge) goal Outcomes that should be achieved upon discharge or transfer to another care setting. Examples IV. PROCEDURES /GUIDELINES (for hypertension) - patient will state importance of taking meds (For pain) patient will report absence or control of pain by discharge (for Diabetes) correctly self administer insulin GENERAL INSTRUCTIONS (see attached form) 1. The care plan is based on assessment of patient needs and must be initiated upon admission 2. Patient s identifying label with name and medical record number must be placed in the upper right hand corner of the form. 3. The Care Plan is kept in the patient s paper chart 4. The nurse assigned to care for the patient is responsible to see that all nursing problems/ diagnoses are documented and current in the Care Plan. 5. Each active problem/diagnosis on the care plan should be addressed each shift in a FOCUS nursing progress note. 6. The goals on the care plan should be used to formulate the a daily goal written on the white board in the patient s room SPECIFIC INSTRUCTIONS: 1. Place date in DATE column when a problem is identified 2. Check off each PROBLEM pertinent to the patient 3. Place INITIALS in initial column next to each problem chosen 2 2

3 GUIDELINES FOR USE OF THE INTERFDISCIPLINARY PLAN OF CARE 4. As problems become resolved indicate DATE OF RESOLUTION in the Resolution column 5. For each preprinted problem, circle the number of the intervention chosen 6. Add additional specific interventions as appropriate 7. Document date, service and signature in each section each time an entry is made on the care plan. 8. Utilize the blank templates to add additional problems/diagnoses to the care plan EXAMPLE of a PLAN OF CARE: Mr. R.S. (diabetic with foot ulcer) PROBLEM: Impaired Skin Integrity related to circulatory impairment, and decreased sensation, (draining wound L foot). Short term goal Be free of purulent drainage within 48 hours Long Term goal Display signs of healing with wound edges clean and pink by discharge Actions/Interventions Wound Care - Irrigate wound with room-temperature sterile normal saline daily Assess wound with each dressing change. Document ulcer status on skin form every shift. PROBLEM: Potential infection from foot ulcer Short term goal Foot will be free of any s/s of infection Long term (Discharge goal) Patient will demonstrate correct dressing technique Patient will verbalize s/s of infection to report to doctor Actions/Interventions (circle which interventions are appropriate for this patient on the preprinted form and add specific interventions for this patient). PROBLEM: Unstable blood glucose related to lack of adherence to diabetes management and inadequate blood glucose monitoring Short term goal Blood glucose will be within normal limits Long term (Discharge goal) Patient will demonstrate correct finger stick technique and willingness to check sugar level as prescribed Actions/Interventions Perform fingerstick BG qid. Administer antidiabetic medications. Teach patient correct technique PROBLEM: acute pain (open wound L foot) Short term goal Patient will report pain is minimized/relieved within 1 hr of analgesic administration (ongoing). Long term goal Report absence or control of pain by discharge Patient will be able to ambulate normally, full weight-bearing by discharge PLAN OF Actions/Interventions 3 3

4 GUIDELINES FOR USE OF THE INTERFDISCIPLINARY PLAN OF CARE (circle which interventions are appropriate for this patient on the preprinted form and add specific interventions for the patient) ATTACHMENTS (See attached sample for more examples) Date Reviewed 10/18/13, 10/22/13 Revision Required Responsible Staff Name and Title (Circle One) Yes No Linda Cohen, RN, Assistant Dir. Nursing Yes No Barry Mandel, Director Social Services Yes No Cheryl Rolston, Linda Cohen, Jacqueline Harry, Linda Cohen, Jennifer McDonald, Lisa Schumann, Michele Fisher 4 4

5 GUIDELINES FOR USE OF THE INTERFDISCIPLINARY PLAN OF CARE PROBLEMGI Bleed Bleeding will subside during hospitalization Long term Patient will be able to state factors that cause bleeding and how to prevent/ minimize 1. Monitor vital signs 2. Monitor labs 3. Prepare for diagnostic tests 4. Assess for s/s bleeding every shift 5. Teach patient causes and ways to prevent/minimize bleeding PROBLEMGrieving ( pt is aware of terminal diagnosis and had palliative care consult express feelings in supportive environment Long term Achieve acceptance stage of death and dying 1. Encourage verbalization of thoughts and concerns 2. Be aware of mood swings - Monitor for signs of severe depression such as statements of hopelessness, desire to end it now 3. Assist patient and family to identify strengths in self or situation and support systems PROBLEMSickle cell crisis Improve oxygenation and perfusion Long term Patient will verbalize understanding of ways to minimize/prevent future crises 1. Monitor respiratory status, breath sounds, use of accessory muscles and vital signs 2. Encourage adequate fluid intake 3. Assess perfusion, skin condition 4. Observe for changes in LOC 5. Maintain accurate I & O weigh daily 6. Teach pt about disease process, treatment plan, precipitating factors, healthy eating, decrease smoking PROBLEMPediatric fear of separation from parents/ support systems Patient will appear relaxed and able to engage in age appropriate activities Long term Child and family begin to deal appropriately with situation 1. Prepare child and SO for treatments and procedures 2. Provide a calm atmosphere 3 Provide comfort measures 4 Provide diversional activities 5. Encourage child and family interaction and normal routines as much as possible 5 5

6 PROBLEM LIST / INTERDISCPLINARY PLAN OF CARE DATE PROBLEM INITIALS DATE OF RESOLUTION PAIN SAFETY INFECTION DISCHARGE PLANNING DISCHARGE PAIN MANAGEMENT HYPERTENSION HYPERGLYCEMIA / HYPOGLYCEMIA PAIN / DISCOMFORT (POTENTIAL) Short term goal Patient will achieve mutually agreed upon goal for pain /discomfort Long term goal Patient will be able to verbalize effective methods to relieve/decrease pain after discharge SAFETY (RISK FOR INJURY) Short term goal Patient will remain free from falls/ injury during hospitalization Long term goal Patient will verbalize techniques to decrease fall risk at home 1. Teach patient about pain scale and encourage patient to verbalize pain 2. Teach pain management control equipment and relaxation techniques and help patient to verbalize pain management goals 3. Assess pain level, quality, characteristics and other factors 4. Medicate as ordered with 5. Reassess as per protocol 6. Document for medication efficacy or lack thereof 1. Utilize the (Morse Scale) Adult Risk/Fall Assessment Tool Q shift 2. Initiate the Fall Prevention Protocols based on the total score (Low Risk, Moderate Risk, High Risk) 3. Assess patient s ability to utilize call bell and assistive devices. Orient patient to environment. 4. Encourage patients to seek help when needed 5. Keep frequently used items within reach to prevent falls 6. Teach patients and family goals of safety during hospitalization 7. Perform Q hourly rounds on patients to assess current needs 8. Document for safety efficacy or lack thereof 6

7 INFECTION (POTENTIAL) Short term goal Patient will be free of infection during hospitalization Long term goal Patient will state ways to reduce risk of infection after discharge 1. Minimize patient s risk of infections through STANDARD UNIVERSAL PRECAUTIONS and encourage patient to do the same 2. Monitor vitals signs as per protocol, report changes to signs to patient s primary team 3. Monitor surgical site (when present), monitor and change IV site and IV tubings as per protocol 4. Send appropriate specimens and monitor labs i.e. UA, UC, CBC, WBC, BLOOD CULTURES, NASAL & GROIN CULTURES etc. and report changes when present to patient s primary team 5. Administer antibiotics as ordered 6. Encourage Incentive Spirometer usage and teach deep breathing exercises 7. DISCHARGE PLANNING/ DISCHARGE PAIN MANAGEMENT (RELATED TO KNOWLEDGE DEFICIT) Short term goal Patient will be able to verbalize his/her own discharge plan Long term goal Patient will achieve each of the goals needed to ensure a safe discharge 1. Teach patient and family from point of admission to discharge 2. Refer patient to appropriate social services 3. Teach patients and family about discharge medications and follow up appointments 4. Teach patient and family about discharge pain management 5. Provide patient teaching leaflets and transportation as needed 6. Document patient s/family s understanding of discharge plans and instructions or lack thereof HYPERTENSION Short term goal Patient will maintain desired blood pressure during hospitalization Long term goal Patient will verbalize knowledge of hypertension management: medications, diet, signs and symptoms to report 1. Monitor vital signs as per protocol, notify patient s primary team of any change 2. Monitor for s/s of HTN and teach patient to report same if present 3. Administer antihypertensive medications as ordered 4. Fax Nutritional Referral as needed 5. Provide Low Sodium Diet and encourage patient to maintain same post hospitalization HYPERGLYCEMIA / HYPOGLYCEMIA Short term goal Patient s blood glucose level will be within desired range Long term goal Patient will verbalize self care skills: healthy eating, being active, taking medications, monitoring, problem solving, reducing risks, and healthy coping 1. Monitor Blood Glucose level as ordered 2. Monitor of s/s of Hyper/Hypoglycemia and teach patient to report same 3. Assess patient s knowledge about diabetes and teach patient and family about diabetes and complications from point of admission to discharge. 4. Teach Patient regarding own diabetic medications 5. Fax referrals to Nutritional and/or diabetic educator as needed 6. Administer oral or subcutaneous medications as ordered 7. Encourage patient to continue glucose monitoring post hospitalization 8. Document all teachings and receptivity of patient to teaching 7

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