Plan that Care!
When creating a care plan, we must ensure we are using the principle of AUTONOMY to guide our process in creating goals and priorities - TRUE or FALSE?
TRUE: the client should always be involved in the care planning process
Mr. Johnson is diaphoretic
He is sweating - we can SEE this, we are using our senses - this is a SIGN, therefore OBJECTIVE DATA
What is a nursing diagnosis?
TRUE or FALSE: family involvement in the care planning process is important, and therefore we must have good communication with all members of the family involved.
TRUE
How can we approach the client in a holistic way?
Include all aspects of care! Physical, emotional, spiritual, social needs - look at the person as a whole and when making the care plan, include all of these aspects!
TRUE or FALSE: we include the family in the care planning process
TRUE: especially during community care planning, the family plays a very important role!
Caleb is complaining that he has a headache
This is something the client is telling us he is experiencing, this is a SYMPTOM, therefore this is SUBJECTIVE DATA
Who creates the list of nursing diagnosis?
NANDA - North American Nursing Diagnosis Association
Page 203 text
Steps involved in community care planning are:
1.) Assessment
2.) Planning
3.) Implementation
4.) Evaluation
What is the Kardex used for?
A summary of information in the chart. Information included: meds, movement (ADLs), dx, tx, assistive devices, routine care measures
TRUE or FALSE: the first step in care planning is EVALUATION
FALSE: we need to first gather important information from our client, we call this ASSESSMENT
I am freezing cold!
Subjective
TRUE or FALSE: this is the order for Care Plans in LTC:
1.) Assessment
2.) Nursing Dx
3.) Planning
4.) Implementation
5.) Evaluation
TRUE!
Who is the care team member involved in the coordination and management of the clients care plan in the community?
Case Manager
Why do we use incident reports?
These are used to record any unexpected events that occur. Can include a near miss, incident, error, accident
TRUE or FALSE: once a care plan is created, it is set in stone once it has been released to all members of the health care team.
FALSE: a care plan is always evolving! As our client's situation changes (improves/declines) we have to always make sure we are working towards goals that make sense to the client based on the changes they are experiencing.
Celine has a 5 cm laceration on her arm that is bleeding
Objective
TRUE: we follow the same steps, but each plan will be unique and specific to the client. It is always changing as we evaluate goals and outcomes.
What does DIPPS stand for?
Dignity
Independence
Preferences
Privacy
Safety
(page 16)
Name some types of DOCUMENTS used in charting:
data form, task sheet, ADL checlist, progress notes (we did this in a previous module!) home assessment forms, specific testing mechanisms (I showed you in class the MMSE and MoCA), assessment forms, graphic sheets, kardex, indcident report, task sheet
TRUE or FALSE: if we notice changes in our client that don't match with the care plan, we call our supervisor, inform them of our findings and document as required.
TRUE TRUE TRUE!
Darren has a skin tear on his left ankle due to a friction/shearing injury
Objective
As a PSW, we can make changes to the care plan as we feel are needed.
FALSE: we are responsible for making observations and reporting changes to the supervisor, who will then initiate changes to the care plan if needed.
Who is the team member involved in assisting the client with their nutrition needs?
The dietician