Effective Date: June 21, 2007

COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 314 Effective Date: June 21, 2007 This Policy replaces NPP 314 dated August 31, 2006 SUBJECT: WELLNESS RECOVERY PLANS (NURSING) 1. PURPOSE: Wellness Recovery Plans are an interdisciplinary team plan based on observations and assessments and provide a road map for future care. The purpose of the plan is to provide a core of information on the Individual s expected outcomes, and planned interventions. The plan serves as a communication tool for staff involved in the Individual s care. Nursing staff, whose contact with one another is limited, rely heavily on the Wellness Recovery plan to ensure continuity of care for the Individual. The plan should guide care, as well as document the planning phase of the nursing process. 2. POLICY: 1. Nursing Services shall provide individualized, goal directed nursing care to all Individuals through the use of the Nursing Process (Assessment, Outcome Identification, Planning, Implementation, and Evaluation). 2. The Registered Nurse: a. Formulates a plan through observation of the Individual s physical condition and behavior and through interpretation of information obtained from the Individual and Wellness Recovery Team members. b. Formulate a plan in collaboration with the Individual which ensures that direct and indirect nursing care services are provided for the Individual s safety, comfort, hygiene, and protection and for disease prevention and restorative measures. c. Performs skills essential to the kind of nursing action to be taken. Explains the health treatment to the Individual and teaches the Individual how to care for health needs. d. Delegates tasks to other nursing services personnel based on their legal scopes of practice and clinical skill capability. Clinically supervises nursing care being given by nursing services staff. e. Evaluates the effectiveness of the plan through observation of the Individual s physical condition and behavior, signs and symptoms of illness, and reactions to treatment and through communication with - 1 -

the Individual and Wellness Recovery Team members. Modifies the plan as needed. f. Acts as the Individual s advocate by initiating action to improve healthcare, changing decisions or activities which are against the interests or wishes of the Individual. Creates opportunity for Individuals to make informed decisions about health care before it is provided. Nursing personnel intervene as guided by the Wellness Recovery Plan goals and interventions in providing care to the individuals. The medical section, Focus 6 of the Wellness Recovery Plan is individualized based on the Nursing Assessment database, the individual s medical conditions, and are consistent with the Wellness Recovery Plan. A preliminary goal and interventions is established and developed by the RN within 8 hours of admission to the unit, then re-evaluated at the 72 Hour Conference. Preliminary plans of care will be established within 8 hours of identification of problem. Once the Team meets for the Wellness and Recovery Treatment Planning Conference, a consensus must be reached regarding the goals for all identified problems. The Wellness Recovery Plan s goal must be consistent with the presenting medical conditions identified by the physician. Whenever a problem is added, changed, or resolved by a mini-team, the RN will be present. The RN will insure that a plan of care is written within 8 hours. The RN may utilize the resource binders (available on the units) as guidelines to write the plan. Other resources for guidance may include the RN Preceptors and HSS. (Health Maintenance) problems do not require a plan. However, only appropriate Health Maintenance problems can be used. When a TC (Temporary Condition) is opened, a brief plan of care with expected outcomes will be identified in the RN s IDN Note. The RN will accomplish this by use of a APIE Note. An RN may call the MOD and take a telephone order to open an emergency physical or psychiatric problem. The RN will record the problem on the Biopsychosocial Profile for Psychosocial or Physical Problems. The RN must initial next to date opened and sign the form with date and full signature. The RN will then initiate a Plan of care, and Individual Problem Plan. A plan of care for Individuals placed into seclusion or restraint may be written in an APIE note or on Side B on the Seclusion and Restraint form. - 2 -

Then outcome criteria (or goal), developed and established by the Wellness Recovery Team, states the expected achievement of the Individual in specific enough terms that any member of the treatment staff can readily determine when the outcome criteria is met. This outcome criterion (goal) can be written in terms of small measurable gains upon which further objectives can be built. The nursing goal is consistent with the Wellness Recovery Team goals. 1. There should be progressive plans written in simple language in order to meet the outcome criteria. 2. The outcome criteria must be one that the Individual realistically can be expected to achieve given the resources available. The Individual and/or significant others should be included in planning the outcome criteria whenever possible. 3. The plan of care is meant to be a collaborative effort between the RN, PT/Primary Counselor, Wellness Recovery Team, and the Individual. Using the short-term Individual care goal developed by the Wellness Recovery Team, the RN in collaboration with nursing services staff, develops and implements interventions that meet that goal. 4. Individual education is given special consideration and must be addressed in each Wellness Recovery plan 5. The length of time that the Individual can reasonably be expected to achieve the outcome criteria is identified within the Target Date section of the Wellness Recovery Plan. 6. The Wellness Recovery Plan shall be reviewed, revised, and/or updated at each conference and whenever clinically indicated. 3. GENERAL INFORMATION, DEFINITIONS: The care plan must be an objective statement that is written in a simple, realistic individualized manner that permits a measurement toward the desired outcome, and is time limited. It needs to adhere to the following definitions: OBJECTIVE- means that the statement should address what can be observed by the senses, without bias, prejudice, or opinion. It is what is real and observable, and different observations would be able to perceive the same data. It is what can be seen, heard, touched, smelled, or tasted. SIMPLE- is a direct statement using the least number of words to make it clear and easy for both staff and Individual to understand. REALISTIC- is a specific behavior, task, or physical condition that is expected to be displayed, that is within the Individual s capabilities, and have a reasonable prospect of success. - 3 -

INDIVIDUALIZED- means that the expected outcome, and planned interventions are specifically designed to address the needs of that particular Individual. MEASUREABLE- indicates that the expected outcome can be observed and measured by another person and is compared with the initial (or subsequent) assessments. The behavior that is observed can be quantified. This covers such parameters as frequency, duration, and amount. (It can also include specific lab value indexes and weight ranges that are indicators of specific behaviors. We cannot measure attitudes and motivations). TIME-LIMITED- refers to a circumscribed period of time in which the interventions will be followed, and progress toward the expected outcome or goal will be measured and evaluated. The length of time that the Individual can be reasonably expected to achieve the outcome criteria needs to be recorded as the target date. The length of time may not exceed a quarter. Goals are often a series of small steps that help the Individual progress toward a long-term goal. It is better to keep the time frame short, and move on to the next step as each goal is met. The Individual will develop a sense of success, and the Wellness Recovery Team will be able to see progress much more readily. The medical conditions Focus 6 of the Wellness Recovery Plan is an essential component of the work that nursing services staff does in providing care and treatment for our Individuals. The Wellness Recovery Plans are based on observations and assessments and provide directions for future care and treatment of the individuals. The purpose of the plan is to provide a core of information on the Individual s medical condition and the expected outcomes, and planned interventions. The Wellness Recovery Plan Focus 6-medical conditions fulfill several functions: Documentation: The plan of care documents the planning phase of the nursing process. Communication: It serves as a communication tool for everyone involved in Individual care. Common goals: It is instrumental in directing nursing services staff to work toward common goals that are individualized to the Individual s needs Continuity: It helps ensure continuity and consistency in care - 4 -

The Wellness Recovery plans are written guidelines of nursing care documenting specific goals, interventions, and projected outcomes. The Planning phase of the Nursing Process is the time to develop a plan of care and determine what approach nursing staff is going to use to help stabilize, lessen, or eliminate the effects of the Individual s problem. The nurse applies the skills of problem solving and decision-making to identify specific Individuals needs. There are three steps in the Planning phase: setting priorities, writing goals, and planning nursing actions. During the Treatment Planning Conference, each member will identify what modalities their particular discipline will provide in helping the Individual achieve the identified short-term goals. The RN will indicate, in general, what modalities will be provided by nursing services staff. The RN is responsible for developing and implementing nursing care. This must specifically spell out the interventions, step by step, what nursing services will provide in helping the Individual meet the short-term goal. Setting Priorities: All open problems must be addressed within the Wellness Recovery Plan. Nursing services staff, the Wellness Recovery Team, and the Individual prioritize the Individual s problems collaboratively. The highest priority medical condition should be treated first. Subsequent problems are ordered in priority. Priority setting does not mean that one problem must be totally resolved before another problem is considered. Problems can frequently be approached simultaneously. Projected Outcome: The Wellness Recovery Team develops the Individual s long and short-term goal(s). Based on the medical condition, the RN writes the nursing specific short-term goal consistent with the Wellness and Recovery Treatment Plan (WRP). Examples: Diabetes: Short-Term Goal: Individual will be able to verbalize how daily exercise can help in controlling his blood sugar level by target date. Short-Term Goal: - 5 -

Individual will be able to verbalize ways that can help in controlling blood sugar levels by target date. Substance Abuse: Short-Term Goal: Individual will verbalize relapse prevention plan by target date Short-Term Goal: Individual will be able to verbalize three coping skills in preventing relapse by target date. ADDITIONAL EXAMPLES: Thought Disorder: Long-Term Goal: Individual will identify and demonstrate behaviors that promote management of mental health Short-Term Goal: Individual will develop a relapse prevention plan as demonstrated by: -Stating s/s of mental illness -Identifying his delusions and developing coping skills for them -Verbalizing risk/benefits and knowledge of treatment Short-Term Goal: (To be accomplished by the next WRP) Individual will state 3 strategies to prevent relapse Delusion/Hallucination: Long-Term Goal: Individual will verbalize understanding of his mental illness and demonstrate its management by: a. Identifying s/s of relapse b. Complying with medication regime c. Complying with and participating in treatment regime Short-Term Goal: (To be accomplished by the next WRP) 1. Individual will identify four symptoms of mental illness 2. Individual will identify his medications and verbalize two reasons for their use - 6 -

Short-Term Goal: (To be accomplished by the next WRP) Individual will identify and state: a. Three signs and symptoms of mental illness b. Two reasons for medication compliance Constipation: Long-Term Goal: 1. Individual will verbalize and demonstrate measures to prevent constipation 2. Individual will experience normal bowel movements QD Short-Term Goal: (To be accomplished by the next WRP) Individual will have one bowel movement QD without straining Short-Term Goal: (To be accomplished by the next WRP) Individual will have one bowel movement QD without straining The advantage to writing the goal directly onto the WRP is that it will provide direction and clarity to nursing services staff in carrying out the plan of intervention for the specific outcome desired for a specific problem number. The goal is designed to guide the team and the Individual as to what the team endeavors to help the Individual accomplish. A goal statement also assists nursing staff to clearly determine if and when the desired outcome has been achieved. The goal may actually be a learning objective, if the medical condition relates to a lack of Individual knowledge or skill. Each progressive short-term goal established requires a series of nursing actions or interventions designed to help the Individual reach the goal. Planning Intervention: The planning and development of interventions defines what nursing services will do to help the Individual reach the desired outcome. Remember that our Individuals are here for treatment, and treatment must be directed at the problems that are interfering with the Individuals health and ability to function safely in the community. Our main task as members of the Wellness and Recovery Team is to come up with treatment options that are effective in diminishing the problems that require treatment and/or hospitalization. Wellness Recovery Plans are developed to specifically address problems that staff can focus on. Nursing actions, or interventions, may be thought of as instructions for all nursing staff caring for the Individual. The RN provides a - 7 -

set of instructions for other nursing services staff on how they are to provide care for a particular Individual. Within the Wellness Recovery Plan are interventions that identify specific nursing care and treatment which nursing personnel have the authority to initiate for a particular Individual. The care and treatments are designed to help the Individual meet one or more goals and lessen an identified problem. They are often written in the form of an order with the frequency of treatment and the date clearly indicated. It is expected that other nursing personnel are accountable for implementation and documentation of nursing orders. (These are part of the plan and just changed to being met and new goals/interventions are identified as needed.) The following suggestions may be helpful as you begin to write the interventions. Nursing action(s) or intervention(s) are designed to help the Individual meet the goal identified by the Wellness Recovery Team. List the interventions sequentially Interventions are phrased in the manner that describes what nursing services staff will do to help the Individual reach the goal. Interventions are specific so that anyone can follow the directions Nursing action(s) or intervention(s) should be phrased to demonstrate how nursing staff would work to reduce or alleviate the Individual s problem behavior. This problem would have been identified in the medical conditions listed by the physician. Interventions should be realistic and appropriate for the nursing staff s level of skill and experience for helping that specific Individual. Interventions should be realistic and appropriate for the nursing staff s level of skill and experience for helping that specific Individual. Whenever possible, the intervention(s) should be important and valued by the Individual, the nursing staff, physician, and Wellness Recovery Team. It should be mutually acceptable so that all the members of the team agree that the intervention is important, realistic, logical, and relevant. Essential Elements of the Wellness Recovery Plan Are: The Registered Nurse is a member of the WRP team. Interventions may be added with collaborative input by other disciplines. Outcome criteria are based on the nursing assessment and shall be realistic, and measurable. The goal must be consistent with the therapy goal identified by the Wellness Recovery Planning Team at the time of the Conference. - 8 -

The Individual, as far as possible, should be included in establishing the outcome criteria. The RN uses the medical condition to develop the plan of care. The medical condition provides the basis for selection of interventions for delivering Individual care that are designed to achieve outcomes, for which the nurse is accountable. The plan of care should reflect current standards of nursing practice. The plan of care shall include nursing actions or interventions that are designed to help the Individual reach the Individual s goal established by the Wellness Recovery Team and will restore and/or maintain the Individual s highest level of functioning. The plan of care will include biopsychosocial aspects, as appropriate. The scope of the plan shall be determined by the anticipated needs of the Individual and shall be revised as needs of the Individual change. Medications requiring nursing interventions must be addressed. Develop a teaching plan. Individual education is given special consideration and addressed in each nursing care plan. Everything we do is geared to discharge. The nursing care plan should include plans to assist the Individual in meeting their discharge criteria as established by the Wellness and Recovery Team. There is no longer a requirement to address discharge specifically. Temporary conditions and acute care situations: An APIE Note will be used when a TC (Temporary Condition) is opened for an acute care situation. When a problem develops that meets the criteria for a temporary condition, the nurse must immediately notify the physician and initiates the documentation requirements for temporary conditions. The IDN to reflect the TC will use the APIE Note format to specifically capture the RN s assessment of the condition and the plan of care to be taken for that condition. If the problem does not meet the criteria for a temporary condition, the RN must notify the physician and obtain a telephone order to open a problem as outlined in the mini-team process (e.g. assaultive or suicidal behavior). Temporary Conditions (TC) may be identified and recorded by either a physician or a Registered Nurse. The RN shall notify the physician when a temporary condition has been identified. Conditions may be designated temporary for duration of 10 days of less with an automatic closure of the condition on or before the 10 th day. If the condition exists longer than 10 days, a problem must be opened by the physician. Temporary Conditions require recording of the planned treatment in a narrative entry including interventions and preventative treatment measures - 9 -

by the RN in the IDN using the APIE format. The Physician will also accomplish this in the Physician s Progress Note. Recording TC entries: Record the entry date and time and Enter TC in the number column and begin the entry with descriptive words or phrases. EXAMPLE: 7/10/05 0830 ENTER TC Laceration This will serve to differentiate entries for more than one TC occurring at the same time. Include a description of the condition or problem and the Individual s input if applicable. Indicate the physician was notified or will be notified of the temporary condition. Record the plan for intervention, observation, preventative treatment measures, etc. A plan is required for each identified condition/problem. Subsequent entries to the same temporary condition shall be entered with date and time and the TV in the number column. Begin with the identifying, descriptive word or phrase, record actions, results and updates of plans. EXAMPLE: 7/12/05 1045 0830 ENTER TC Laceration Recording EXIT TC identifies the final entry for a given temporary condition. Only a physician may exit a temporary condition. However, it is permissible for the physician to give a telephone order to the Registered Nurse to exit a Temporary Condition and to discontinue related physician orders. Nursing staff should exit the Temporary Condition in the Wellness and Recovery/Discipline Specific Notes at the time the physician exits the Temporary Condition in the physician s progress notes or at the time of the telephone or verbal order by the physician. In order to develop and initiate a timely plan of care for an acute care situation(s) and to address when a TV is opened, use of APIE Charting will be utilized for charting of TC s. Use the APIE format each time the TC problem is addressed until TC is closed. Problem Oriented Charting (APIE) reflects certain aspects of the nursing process and consists of the following format: A: assessment (what you think is going on based on the data) P: plan (what you are going to do) I: Intervention E: Evaluation Non-temporary conditions: - 10 -

Conditions requiring oral or parenteral antibiotics. Any condition requiring other than topical antibiotics, regardless of duration of the condition for which why are prescribed, shall not be designated as a temporary condition. Chronic recurring temporary conditions: Conditions which recur more than once per quarter shall not be designated as temporary conditions even if they are short term conditions. After the first occurrence these conditions should be listed in the Wellness Recovery Plan. Conditions requiring seclusion or restraint: Such conditions shall be keyed to the appropriate problem number in the Wellness Recovery Plan. Legal implications: Plans of care should have the following characteristics: Completeness- each problem identified through observation and assessment must be addressed in the plan of care. Realism- failure to follow the plan can be interpreted as breach of the institution s own standard of nursing care. Therefore, the plan of care must be realistic so that they can be complied with. Currency- as the Individual s condition changes, the plan of care must be updated. Failure to follow the plan simply because it is outdated may still be difficult to defend in a court of law. The Wellness Recovery Plan is reviewed, revised, and/or updated at the Quarterly Conference. - 11 -