Review Flashcards
(26 cards)
Care planning process in facilities
Method used to plan and deliver care in nursing homes
5 planning process
Assessment Nursing diagnosis Planning Implementing Evaluation
Assessment
- Collecting information about the client
- assessment of the clients emotion
Support workers play a key role in assessment
- Make observations and talk to the client
- report and record their findings
Nursing diagnosis
- RN uses assessment information to make a nursing diagnosis
- needs are arranged in order of importance
The nursing care plan
Written guide about clients care
Is a communication tool
Uses by nursing staff to see what care to give
Implementation
Performing out the actions in the care plan
Four main functions
- providing the care
- observing the client durning care
- report and record care
- report and record observations durning the care
*reporting and recording are done after giving care, not before
Evaluation
Measuring wheather goals in the planning step were meet
Care planning process in community settings
Also includes assessment, planning, implementation and evaluation
Planning
- the case manager, client and family establish priorities
- includes services provided by family members outside professionals
Implementation
- Provide care in the date and time arranged by case manager
- unforeseen needs may arise
Evaluation
Is ongoing
Support worker role in the care planning process
Nurses uses support workers observations and feedback in care planning process
Developing observation skills
- Support workers spend more time with clients
- be alert to changes in clients conditions or behaviours
Objective data
Information observer about the client
Subjective data
Information reported by a client on hat is not observed
Communication
The exchange of information
Verbal reporting
Be through and accurate
Give client name & room number
Give time when care was given
Immediately report any changes in the client
Client records or charts
- chart is a legal document with the clients conditions, signs and symptoms
- files are kept from admission to discharge or death
Documentation
Communications
Planing client care
Quality assurance
Funding
Documents used in charts
Data forms
Includes physical, emotions, social and cognitive health
Assessment forms
Identifying a problem area
Home assessment
Documents changes that need to be made to a clients home