Prioritizing The Nursing Problem List

1. 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

2. Objectives • Describe components of the plan of care • State the value of using evidence based care planning terms • Understand the CCC Nursing terminology model within HED • Develop & Document a usable care plan using CCC problem (Dx) list

3. 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

4. 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

5. 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 . . .

6. The clinical team implements the medical plan of care (orders) and contributes its own specialty focus by Assessment Diagnosis Plan Intervention Outcome evaluation Plans of Care

7. 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

8. Nursing diagnoses = Problem List • Nursing diagnosis is "a clinical judgmentabout individual, family, or community responses to actual or potential health problems/life processes. • Nursing diagnoses provide the basis for selection of nursinginterventions to achieve outcomes for which the nurse is accountable" (NANDA, 1992 p. 5). They describe clinical nursing practice in a uniform manner.

9. Evidence Base • The 182 Clinical Care Classification* (CCC) problems (dx) were derived from 40,361 nursing diagnosesand/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

10. CCC Frameworkfor the Nursing Plan of Care • 21 Categories: Skin Integrity 182 Problems (Dx): Oral Mucous Membranes Impairment 3 Expected Outcomes:Improve, Stabilize, Support decline 198 Interventions: Mouth Care 4 Actions:Assess, Care, Teach, Manage 3 Actual Outcome:Improved, Stabilized, Decline supported

11. Physiological 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 21 CCC Categories

12. 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

13. 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.

15. ____________________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 Excess May be related to: CHF, fluid intake, hi Na diet Exp Outcome: Stabilize ______________________q shift plan and outcomes__________________ Exp Outcome Detail: diurese .5L this shift Exp Outcome Status: Not Met Interventions: chart as usual Plan of Care admission documentation

16. Activity Problems • Activity Alteration Change in or modification of energy used by the body • Activity Intolerance Incapacity to carry out physiological or psychological daily activities • Activity Intolerance Risk Increased chance of an incapacity to carry out physiological or psychological daily activities • Activity Indifference Lack of interest or engagement in leisure activities • Fatigue Exhaustion that interferes with physical and mental activities • Mobility Impairment Diminished ability to perform independent movement • Sleep Pattern Alteration Imbalance in the normal sleep/wake cycle • Sleep Deprived Lack of the normal sleep / wake cycle • MuscSkeletal Alt Change in or modification of the muscles, bones or support structures Alt = Alteration

17. Physical Regulation • Physical Reg-Oth • Change in or modification of somatic control • Hyperreflexia • Life threatening inhibited sympathetic response to a noxious stimuli in a person with a spinal cord injury at T7 or above • Hyperthermia • Abnormal high body temperature • Hypothermia • Abnormal low body temperature • Thermoregulatory Impairment • Fluctuation of temperature between hypothermia and hyperthermia • Infection Risk • Increased change of contamination with disease-producing germs • Infection • Contamination with disease-producing germs • IntrCranialFluid • Intracranial fluid volumes are compromised

18. 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)

19. 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 -------

20. 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.

21. Plan of Care Report Available now in Standard HED format (many pages – not well formatted) Use as Backup When paper is required i.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.

22. Phase II - CCC Interventions • Example • Skin Integrity • Wound Care • Modifiers: • Assess wound care • Perform wound care • Teach wound care • Manage wound care (consult)

23. 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

24. 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

25. Graphical Display of Priority Problems Problems key:  Priority  Resolving  Resolved 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

26. Graphical Display of Priority Problems Charge Nurse View Entire unit Possible C-Diff outbreak

27. Graphical Display of Priority Problems Exec View Entire Hospital Highlights Discharge Concerns Or Opportunities For targeted education & surveillance

28. Spread the word • Look for opportunities to use the CCC terms framework in your current work.

29. 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