PrioritizingThe Nursing Problem List

Using the Clinical Care Classification- an evidence based Nursing terminology

in the patient’s plan of care

deborah.ariosto@vanderbilt.edu

Objectives

1. Describe components of the plan of care

2. State the value of using evidence based care planning terms

3. Understand the CCC Nursing terminology model within HED

4. Develop & Document a usable care plan using CCC problem (Dx) list

VUMC Multi-DisciplinaryPlan of Care

1 Pathway & Phase Sets timed objectives to

meet discharge goals based on predominant medical or surgical plan

2 Provider Plan Orders & planned

procedures

3 Multi-Disciplinary Plans Reflects provider orders Contributes specialty

focus

4 Reflects patient goals

Pathway & Phase

Choose the pathway that most closely reflects the expected patient progression. Usually the reason for admission.

Medical Pathway – Heart Failure Admission – Orders & interventions are aimed at

achieving stabilization ( improving pump action through diuresis, O2, hemodynamic stability, . . .)

Stabilization - achieving a controlled symptoms (fluid excess control, med mgmt

Discharge – Ready for self-care; or care by another caregiver.

Surgical Pathway - Knee Replacement Pre-op Pre; Post-op Stabilization; Discharge

Managing/preventing problems can help reduce length of stay and improve the quality and cost bottom line

Adverse patient effects hospital acquired conditions (infections, injuries) dissatisfaction (unhappy, lost wages) . . .

Adverse VUMC effects lost revenue from under-reimbursed care days losing patients due to having no available beds . . .

- 2 4 6 8

Extended LOS (under-reimbursed)

Expected LOS

Days

Phase

Pathway ProgressionMedical/Surgical Phases

I: Admission/Pre-Op

II: Stabilization/Post-op

Problem: Infection/Fall

III: Discharge

Problem: Discharge Delay

Medical Plan of Care

Multi-D Plan of Care

Nursing Plan of Care

The clinical team implements the medical plan of care (orders)andcontributes its own specialty focus by

Assessment Diagnosis Plan Intervention Outcome evaluation

Plans of Care

Assessment

Standards of Care (SOC*) Physical Assessment (standard met/not met) Past medical/surgical/functional Assessment Baseline vital signs . . . Screening scales: braden, fall, confusion, pain

Population based SOC Scales: Glascow coma, RASS, . . . More frequent and complex targeted

assessment Mosby’s evidenced based guidelines (diabetes

…)

* SOC – care administered without need for orders

Nursing diagnoses = Problem List

Nursing diagnosis is "a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable" (NANDA, 1992 p. 5). They describe clinical nursing practice in a uniform manner.

Evidence Base

The 182 Clinical Care Classification* (CCC) problems (dx) were derived from 40,361 nursing diagnoses and/or patient problems collected from the research study patients for an entire episode of care as requiring nursing services including the actual outcome on discharge.

Standardizing our clinical terms helps us share patient info across settings and disciplines; allows us to empirically test our interventions and build new evidence to advance the profession

*Developed by Virginia K. Saba, RN , PhD

CCC Frameworkfor the Nursing Plan of Care

21 Categories: Skin Integrity182 Problems (Dx): Oral Mucous Membranes Impairment 3 Expected Outcomes: Improve, Stabilize,

Support decline198 Interventions: Mouth Care4 Actions: Assess, Care, Teach, Manage3 Actual Outcome: Improved, Stabilized, Decline

supported

21 CCC CategoriesPhysiological

Cardiac Bowel/Gastric Life cycle (pregnancy) Metabolic (glucose) Physical Regulation (infection) Respiratory Skin Integrity Tissue Perfusion Urinary

Medication

Psych/Behavioral Cognitive Coping Health Behavior Role Relationship Self Care Self Concept

Functional Activity Fluid Volume Nutrition Safety Sensory/Pain

CCC Problem Coding*59 major & 123 sub-categories

Category (R) Skin Integrity R46 Skin Integrity Alteration Change in or modification of skin

conditions R46.1 Oral Mucous Membranes Impairment R46.2 Skin Integrity Impairment R46.3 Skin Integrity Impairment Risk R46.4 Skin Incision R46.5 Latex Allergy

R47 Peripheral Alteration  Change in or modification of vascularization of

the extremities *CCC codes map directly to multi-d concepts (SNOMED) supported by NLM

3 CCC OutcomesExpected/Actual

1. Improve/Improved Condition will change and/or recover (fracture,

pneumonia)

2. Stabilize/Stabilized Underlying Condition will not change but requires no

further nursing care to maintain (asthma, heart failure)

3. Support Decline/Decline Supported Condition will change and worsen (cancer, ESRD).

Nursing action supports decline.

Plan of Care admission documentation____________________Plan of Care Summary________________________Pathway: CHF (chart once) Phase: Admission (update prn)

Nsg Summary: Pt admitted via ambulance in respiratory distress…Plan Priorities: IV diuretics, fluid restrictions, I&O, reduce anxiety….____________________Initial Problem______________________________Priority Problem: Fluid Volume ExcessMay be related to: CHF, fluid intake, hi Na dietExp Outcome: Stabilize______________________q shift plan and outcomes__________________Exp Outcome Detail: diurese .5L this shiftExp Outcome Status: Not Met

Interventions: chart as usual

Activity Problems

 Activity AlterationChange in or modification of energy used by the body

Activity IntoleranceIncapacity to carry out physiological or psychological daily

activities

Activity Intolerance RiskIncreased chance of an incapacity to carry out physiological or

psychological daily activities

Activity IndifferenceLack of interest or engagement in leisure activities

FatigueExhaustion that interferes with physical and mental activities

Mobility ImpairmentDiminished ability to perform independent movement

Sleep Pattern AlterationImbalance in the normal sleep/wake cycle

Sleep DeprivedLack of the normal sleep / wake cycle

MuscSkeletal AltChange in or modification of the muscles, bones or support

structures

Alt = Alteration

Physical Regulati

on

 Physical Reg-OthChange in or modification of somatic control

HyperreflexiaLife threatening inhibited sympathetic response to a noxious stimuli in a person with a spinal cord injury at T7 or above

HyperthermiaAbnormal high body temperature

HypothermiaAbnormal low body temperature

Thermoregulatory ImpairmentFluctuation of temperature between hypothermia and hyperthermia

Infection RiskIncreased change of contamination with disease-producing germs

Infection

Contamination with disease-producing germs

IntrCranialFluid Intracranial fluid volumes are compromised

Prioritizing Problems

Patients have many problems, what makes it a priority problem?

When it Is the patient’s priority (pain, SOB, anxiety) Keeps the patient from moving to the next phase (fluid

volume excess) High probability for harm (infection risk, falls) Delays discharge

Note that Day & Night shift may have different priorities (ambulation vs. sleep)

Choosing the best problem descriptor

Choose the problem that most closely aligns with the interventions that you will do for this phase.

My pt has Heart Failure – which problem do I pick?

If you are focusing on fluid mgmt (IV diuretics, I&O, lo Na diet, fluid restriction) pick Fluid Volume Excess

If you are focusing on breathing treatments, choose Respiratory Alteration

-------Neither are wrong – both may be selected -------

Maintaining a short - usable Problem list

Initiate problems thoughtfully & miserly – do not replicate standards of care unless they are a priority problem that you are actively monitoring or treating.

Where possible, maintain the problems that have been started by the previous nurse until there has been significant progress towards goals or the problem has been resolved. Do not change for a slightly better descriptor.

Not all problems need be addressed every shift – day and night shift will have different priorities

Use the HED significance flag ! Plan Priorities reflects priorities for the next 12 hr.

Plan of Care ReportAvailable now in Standard HED format(many pages – not well formatted)

Use as Backup When paper is requiredi.e. Transfer to another facility

August 2010:

A 1-2 page plan of care summary will be available.

Goal – create a paper plan of care that can be used in bedside report and given to the patient and family.

Phase II - CCC Interventions

ExampleSkin IntegrityWound CareModifiers:1. Assess wound care2. Perform wound care3. Teach wound care4. Manage wound care (consult)

Future: HED documentation will be mapped to the action types

RESPIRATORY CARE COMPONENT

(1) Assess Breath Sounds

RUL RLL LUL LLL

SOB etc.

(2) Perform Oxygen Therapy Care Breathing Exercises Chest PT Inhalation Ventilator Care Trach Care

(3) Manage/Refer/Notify(4) Teach

Phase III – Reports & Views

1. Printed Plan of Care to share with the patient and/or upload to MyHealth@V

2. Visualizing the problem list through Dashboards•Staff Nurse View•Unit Manager View•Exec/Admin Views

Graphical Display of Priority Problems

Staff Nurse View cues to:

#1 CHF : Monitor cardiac, perfusion, fluid balance, resp#2 Diabetic: Monitor glucose, diet, and skin#3 CABG: Ambulate CABG & protect from falls#4 Unknown: Diarrhea, fever, hypercapneic

Problems key: Priority Resolving Resolved

Graphical Display of Priority Problems

Charge Nurse ViewEntire unitPossible C-Diff outbreak

Graphical Display of Priority Problems

Exec ViewEntire HospitalHighlights Discharge ConcernsOrOpportunitiesFor targeted education & surveillance

Spread the word

Look for opportunities to use the CCC terms framework in your current work.

Plan of Care Exercise

Think about a recent patient and review their pathway

•Fracture•Burn•Asthma•COPD

Check of 3-5 high priority problems from the handout

Refer to Mosby’s evidence based plans of care if needed