Nursing process

With care planning, a portion of the nursing process is referred to in the professional health and nursing and care for the elderly, to structure the collaboration with the nursing documentation contributes targeted nursing actions to systematically identify, implement and evaluate. Result of care planning is the writing detained care plan that provides all the relevant information to care for the implementation of nursing interventions in the care involved. Within the nursing care plan based on the individually tailored to a care recipient care needs nursing objectives defined and planned and documented the necessary to achieve the desired result nursing care measures.

Distinction between

The care plan is a tool for practical implementation of the nursing process. It enables a goal-oriented, systematic, structured and logical action and therefore sets itself apart from the laity care. You and also the nursing documentation are often confused in the German daily care with the nursing process, this can be attributed mainly to the lack of agency nursing science and academic foundations during and after nursing education. During a basic opinion of the medical service of the peak associations of sickness funds is determined that it is assumed in the nursing professional practice due to a lack of mediation of the relationship between nursing process and respective nursing documentation, that as with the mandatory by statutory requirements completing the Dokumentionssystems the nursing process and thus the care planning procedure takes place.

Position of the care planning in nursing process

The nursing care plan is part of the internationally established as the basis of nursing action working method of the nursing process. This is an abstract method for problem solving and analytical model of action, repeating cyclically, based on and interacting phases. The, also known as care -loop process is based not only nursing science work on findings from systems theory, cybernetics, and decision theory. Are widespread models with four, five or six phases, the terms used for the different phases are not uniform, however, include all the models the step of care planning. The planning phase is embedded according to the information collection or nursing assessment and nursing diagnosis or the identification of resources and maintenance problems. The care plan serves as a basis for action for the next step of nursing intervention, the actual implementation of care.

Tabular comparison

In the spread in Germany six-phase maintenance process model by Fiechter and Meier care planning is the determination of the nursing objectives and care planning divided again, but by Yura and Walsh, this separation has no effect on the nursing result itself a result of the work Monika Krohwinkels, the sharper notion delimitation and However, logical superiority wins the four-phase model increasingly influence in the German care.

In a table, the position of the care planning in the various nursing process models compare:

For a successful implementation of the plan, the initial assessment to determine the targets and the repeated evaluation for feedback from the nursing process are crucial. Without the regular correction of planning the implementation is wrong and possibly a later date the planning process with the progress so that only gives back to reschedule a valid working basis for implementation. As far as the information collection follows without delay the implementation, this divergence of process and plan can be avoided on the basis of information collection by progressive correction of the planning.

Elements of care planning

Care goals

In the first step of the nursing process, the information collection or assessment, all available care-relevant information is collected, which serve to identify the care needs of the care recipient. They include the so-called master data, the physical and mental state as well as the habits of the patient. Checklists and various nursing assessment instruments may be used to collect additional data. Additional sources of information are, for example, details of relatives, previous nursing course plans, the medical case history and observations of other professional groups. Based on this nursing problems and resources identified and documented to determine the actual state. Areas of life in which no nursing intervention is necessary, accordingly, have no goal orientation and are not included in practice in care planning. Starting from the identified nursing problems of the caregiver or family members are from the patient himself, defines nursing goals that are based on the priorities identified in the history of nursing problems and select the appropriate care priorities. This care can provide targets the target state dar. distinction is made according to Fiechtner and Meier in long-term goals to be achieved in the long and short-term goals that can be achieved in the foreseeable future or represent a partial step towards a long-term goal can. Regardless of this classification, all targets are formulated so that they describe a realistic, achievable and objectively verifiable care results. This includes not only a concrete description of the objective, the reduction of a time frame for the review of the achievement of objectives. Contents of a maintenance goal can be or relate to his physical condition or measurable changes, for example, the behavior, skills and abilities, the development and the knowledge of the patient.

Examples of a defined target care after widespread in Germany model of the promotional process maintenance can be:

• Maintain AEDL yourself: Mrs. M. washes in a week the face itself
• AEDL food and drink: Mr. R. takes a month to one kilogram.
• AEDL yourself deal: Mr. K. would like to find meaningful employment in his new environment after moving.

Care measures

To achieve the stated objectives care plan nurse and nursing care together the concrete measures management measures. This also designated as a nursing intervention actions are considered the application of nursing and interpersonal skills, informing and consulting the care recipient and the organization and the delegation of work defined. When planning in addition to the needs and resources of the patient and his relatives, the institutional framework such as staffing levels and care should be considered. The formulation of the measures must be precise, clear and understandable, the parameter type, quality and temporal distances of the actions should be described; as mnemonic here is also: " Who, what, what, when, how often " used. If standards of care or expert standards are defined, the mention of which is enough, but they do not replace the obligation to individual planning, but also facilitate the planning of actions under frequently occurring maintenance problems. In Germany, for a description of the management measures and the supply to the implementation following documentation package descriptions complete takeover ( VÜ ), partial takeover ( TÜ ), support (U), as well as advice, guidance and supervision (BA ) for the indication of the extent of the usual care and meet the underlying legal requirements.

Examples of maintenance actions based on the nursing objectives:

• AEDL maintain yourself: Guidance on the face wash in the morning at 7.30 clock personal care by the nurse.
• AEDL food and drink: Prepare and offer for all meals in consultation with the preferred cuisine dishes as well as additional snacks at 15.00 to 22.00 clock.
• AEDL yourself deal: Accompaniment and transport to the elderly or infirm group on Wednesday at 16.00 clock and seniors brunch on Saturday at 10.30 clock by the community service workers. Mr. K. and relatives informed by the social services regularly also held offers.

Is that true care result in the final evaluation is not the target match, the reasons are analyzed for this purpose. Possible reasons may be a lack of information collection, a misjudgment of the situation or of the care needs, to a wide setting of care or objective planning undue care measures. This is followed by an adaptation of the care plan to the actual situation, reached care goals lose priority, newly emerged or did not reach objectives are identified and planned.

Documentation and development of a care plan

The planning has the character of a nursing Regulation and is binding on all parties involved in the care. In the care plan to the assessment phases of the nursing process are processed in written or virtual form, usually the identified nursing problems, skills and resources to care objectives, management measures and their verification are associated with each other. The deposit of the care planning as a care plan serves on the one hand the technical securing continuity of care in the course and granted to all those involved in the maintenance of access to the necessary information about the nursing practice to perform. The Care Plan is considered to be one of the key documents within nursing documentation systems by which quality control (evaluation) of Soll-/Ist-Zustand be objectively assessed and the service provided can be transparently. As part of the care plan, all performed maintenance measures should be documented promptly and Close to the village of hands or signature of the caregiver. If measures are not carried out is to document this, giving reasons also. This is the traceability of care performance. This legal requirements be satisfied, or the quality of care rendered can be attended in the legal sense of the evidence.

Example: Typical structure of a plan of care in a simplified representation

Reporting guidelines for creating an individual care plan

In nursing practice sometimes consist formulation difficulties in care planning. Therefore, there is incomplete or inconclusive wording in the care planning. Support can provide standardized nursing classifications here. You have classified nursing problems / nursing diagnoses, nursing objectives and / or care measures.

The best-known nursing classification systems in the German-speaking area are the following:

• European Nursing Care Pathways (ENP ) classifies nursing diagnoses, nursing objectives and management measures.
• International Classification of Nursing Practice ( ICNP ) using the concepts of the different axes both statements on nursing diagnoses, and care outcome measure can be developed post combinatorially by the caregiver.
• Service Entry in Nursing ( LEP) classified care services
• North American Nursing Diagnoses Association ( NANDA ) nursing diagnoses classified.
• Nursing Outcome Classification ( NOC) classifies nursing outcomes
• Nursing Intervention Classification ( NIC) classifies nursing interventions.

Worldwide, there are numerous other nursing classification systems which nursing diagnoses, goals and describe actions and could be used to nursing process documentation.

Position of other professional groups in care planning and documentation

The coordination and consultation with other professionals, such as doctors, speech therapists or physical therapist is an integral part of the nursing activity. With the documentation of the nursing process offering them access to the care-relevant information, decisions and actions. However, the respective arrangements such as prescribing medication or treatment care are not part of the actual care planning but will be registered in the nursing documentation system or the care plan. Basically, the other occupational groups in the access to the documentation should be made possible, so that they automatically enter the appropriate arrangements and sign and to get an overview of the nursing course or their own observations that have an impact on the care measures can be documented in the care plan. Typical documents in this context are, for example, the fever curve, which are used by nurses and doctors to monitor the progress of vital signs or the wound documentation in the ordered wound care can be coordinated with the physician or wound Manager.