IPOC Optimized November 2012 1 - · PDF file · 2014-03-19Care are created from Nursing Diagnoses. Common Language ... *Nutritional Deficit *Pain *Activity Intolerance ... plan of

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IPOC Optimized November 2012 1

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•Describe the Nursing Process as the framework for a patient Plan of Care.

Critical Thinking Model

•Describe how Plans of Care are created from Nursing Diagnoses.

Common Language

•Describe how the caritas process applies to the Interdisciplinary Plan of Care (IPOC).

Theory of Human Caring

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*The Nursing Process, a critical thinking model, includes the patient-specific Assessment, Diagnosis, Planning, Implementation and Evaluation, and is the foundation for a well-developed IPOC.

*Recognizing the uniqueness of each patient and the provision of individualized care is accomplished through the use of comprehensive and standardized language (I.e.: Nursing Diagnosis).

*The Caritas Process (of the Theory of Human Caring) is used as an expressive tool to guide and further deepen the meaning of the Plans of Care developed for each patient.

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* Nursing Process - the diagnosis and treatment of

human responses to actual and potential health problems. American Nurses Association (ANA) Social Policy Statement of 1980

Assess

Plan

Implement

Evaluate

Nursing

Diagnosis

The Nursing Process includes: Assessment Diagnosis Plan Implementation Evaluation

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All caregivers… 1. Collects data

2. Identifies patient needs

3. Establishes goals & creates measurable outcomes

4. Selects interventions to assist patient in achieving the outcomes & goals

5. Evaluates the outcomes

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Assessing

Diagnosing

Planning Implementing

Evaluating

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*Registered Nurse

*Respiratory Therapist

*Physical Therapist

*Occupational Therapist

*Speech Therapist

*Registered Dietitian

*Specialists: Wound Care, Diabetes, Stroke, etc.

*Infection Control

*Care Manager & Social Worker

*Pharmacist

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*Determine appropriate

plan

*Provide standard language

*Drives interventions and

patient outcomes

*Consistent and accurate

documentation

http://www.nanda.org/NursingDiagnosisFAQ.aspx

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*Three major elements of the Caring

Theory

caritas process

transpersonal caring relationship

caring occasion/caring moment

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Larry, a 65 year-old male, is 24 hours post-open

cholecystectomy. He has a history of smoking, COPD,

DVTs, and an allergy to penicillin. He states he “fell

once” a few weeks ago. He is homeless, and states he

is not interested in receiving any information on

outpatient clinics for follow-up care when he is

discharged. A clear liquid diet was not tolerated by

Larry; he complains of severe nausea and abdominal

pain 8 out of 10 on the pain scale. You note that Larry

quickly becomes fatigued with any physical activity.

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*The RN notes that Larry has a history of falls

* The Care Manager notes that Larry is homeless and

is refusing follow up care

* The RN notes that Larry needs moderate assistance

with his hygiene needs

*The Registered Dietitian notes that Larry is not

tolerating his diet

*The RN notes Larry’s pain level remains high despite

current therapy

*The Physical Therapist notes that Larry has

difficulty breathing and becomes fatigued with

activity

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*Risk for Injury

*Discharge Needs

*Self Care Deficit

*Nutritional Deficit

*Pain

*Activity Intolerance

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*Think of the Plan of Care as a living document that evolves

throughout the patient’s stay

*An assessment by one discipline could potentially identify

a problem/goal in another area

*For example, PT’s findings uncovered Larry’s respiratory

problem

*Follow up to identified problems/goals can – and should -

be performed by multiple disciplines as appropriate

*Can I document on the same goals or interventions as another

discipline? Yes!

*Can I remove or add goals or interventions to the Plans of

Care, even if identified by another discipline? Yes!

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*Through assessment and documentation of

individual patients, plans of care are suggested

to the caregiver

*The first step in prioritization is that the

caregiver evaluates the recommended plans,

accepts them or does not accept them, and

indicates goals. You also have the ability to

add care plans that are not suggested if

applicable.

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*Plans of care should be specific to the

patient and specific to why they are

hospitalized. For Example:

*A patient with a history of hypertension, but is

not admitted for HTN this visit, should not have a

plan of care related to elevated blood pressure –

only if it is an issue this hospitalization.

* If an elevation of BP occurs with other triggers

during the stay, the plan would be recommended

at that time.

* The Interdisciplinary Plans of Care should

be manageable and meaningful for

improved health during this

hospitalization.

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*At change of shift, interdisciplinary rounds,

and handoffs, the Plan of Care Summary

should be reviewed and the prioritizations of

the problems discussed.

* There is no numbering; the documentation

against the progression of the goals and any

addition/discontinuation of goals is evidence of

prioritization.

*This is an active, evolving list of problems to

guide the care of the patient and by addressing

progress, discontinuing, or adding care plans

we are prioritizing what is needed for that

patient at the current time.

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*The steps of prioritization are as stated –

initial and continued prioritization based

on active use of the care plans and

documentation of progression

*From a JC standpoint, what is emphasized

is that caregivers can talk about how they

prioritize plans of care for their patients.

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*Our goal has been to ensure

understanding of the care planning

process by all members of the

interdisciplinary team.

*The new optimized IPOC allows us to

create patient-centric plans of care.

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