Transcript The Nursing Problem List

Nurses reviewing other nurse’s documentation during
the handover process find it hard to identify care
priorities to focus on
Paper Pathways are not easy to find in the pt’s chart, not
part of the electronic record & nurses feel that printing is
just busy work
Managers & Regulators reviewing nursing
documentation find it difficult to determine the most
important patient problems – Recent JCAHO survey
prompted us to try changes

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
8 VCH & 8S VUH piloted a new way to document in
HED…. “Priority Problems”
Nurses like it because it’s easier to plan & manage
patient care. Terminology is standardized and
simplified using CCC Saba model.
Nurses find that documenting “Priority Problems” is a
PRACTICE change with no new computer skills to
learn
Verbalize understanding of the vision for Priority Problems and
Clinical Care Classification* (CCC) Nursing terminology.
Use CCC Nursing terminology to document planning and
managing care for a practice scenario. Including
•
•
•
Assign & save a pathway to a patient’s medical record in StarPanel
Initiating 2-3 top priority problems and their expected and actual
outcomes
Documenting shift expected/actual goals, Nursing Summary and
Plans
For your area, initiate list of top 10 pathways and 5 problems for
each. Define for common problems the problem category,
problem, related to…., expected outcomes and short term goals
Priority problems will simplify and standardize
how nurses:

document and communicate the patient’s top priority
problems

identify plans and goals

assess actual outcomes
This will improve patient care and clearly define nursing’s
contributions to patient care and the team.


Save Electronic copy of Pathway in StarPanel
Identify 2-3 priority patient problems and
outcomes and short term expected/actual goals
using CCC model
WHY? Nurses, and all team members, need to focus on the
most urgent needs & identifying the interventions to help
patients achieve their goals.
Not Changing:
Document the pathway name, phase, nursing summary & plan priority
in HED
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We all have different ways of describing or talking about
problems. You call it pain, I call it alteration in comfort
The decision was made to standardize how we talk about
nursing care. The Clinical Care Classification* (CCC) Saba
Model was selected.
Over 40,000 charts were reviewed to
derive the 182 Clinical Care
Classification problems.
The Clinical Care Classification (CCC)
System* is a standardized, coded
nursing terminology that identifies
the specific elements of nursing
practice.
CCC provides a unique framework and
coding structure for capturing the
essence of patient care in all health
care settings
*Developed by Virginia K. Saba, RN , PhD
You can learn more on the Sabacare.com website
about the CCC.
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21 Categories w/82 Problems

3 Expected Outcomes
◦ Improve
◦ Stabilize
◦ Support decline

3 Actual Outcomes
◦ Improved
◦ Stabilized
◦ Decline supported
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
1. Improve/Improved
Condition will change and/or recover (fracture, pneumonia)
2. Stabilize/Stabilized
Underlying chronic 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.
Putting it all together to
Build an Outcome Oriented
Documentation Framework
• Select & Save Pathway (StarPanel )
• Document Pathway Name & Phase (HED)
Admission
• Create 2-3 Priority Problems (HED)
• Review Pathway & Phase - change prn (HED)
Beginning
of Shift
• Document expected Short Term Goals for your shift (HED)
• Start/End Priority Problems - adjust Pathway & Phase prn (HED)
• Document Short Term Goal Status or outcome (HED)
End of Shift
• Document Nursing Summary & Plan & Priorities for next shift (HED)
• Start/End Priority Problems. Change Pathway &/or Phase prn.
• Document Short Term Goal & status (HED)
Transfer/
Discharge
• Document Nursing Summary & Plan & Priorities in HED
• Document D/C Plan in HED & denote Post Discharge Plans to address
unmet goals
Select & Save Pathway (StarPanel )
 Document Pathway Name & Phase (HED)
 Create 2-3 Priority Problems (HED)

Admission
Day of
go-live
also
Choose the pathway that most closely reflects the expected
patient progression. Usually the reason for admission.
EXAMPLES:
Medical Pathway – Heart Failure
Admission – Orders & interventions are aimed at achieving stabilization
(improving pump action through diuresis, O2, hemodynamic stability, . . .)
Stabilization - achieving controlled symptoms (fluid excess control, med mgmt)
Discharge – Ready for self-care; or care by another caregiver.
Surgical Pathway - Knee Replacement
Pre-op
Post-op Stabilization
Discharge
Specific pathways will
have phases, goals and
interventions that are a
better fit.
The evidenced based
pathways can better
guide care.
Use generic pathways
only as a last resort
Select & Save Pathway (StarBrowser/StarPanel )
 Document Pathway Name & Phase (HED)
 Create 2-3 Priority Problems (HED)

Admission
1.
Click Action
2.
Click EDOCS
Pathway
List of pathways
display
3. Type the name of
the pathway in
search.
4. Click on Pathway to
add to medical
record
5. Click OK to add to
Starpanel
Pathway Will Display in Assessment Section of
the OPC with a Link for Easy Access
Click to display
pathway
You are working day shift and your 27 yo ,Mary Lou was admitted to the Ortho
unit around 5pm after an MRI revealed a cervical cord mass. She is
experiencing weakness, is ataxic and has neck and back pain. Her pain
score is a 5 with morphine on board. She is scheduled for a cervical
laminectomy tomorrow. She is a single mother and concerned about her 4
and 2 year old children and how she will care for them after surgery.
1. Assign best fit Pathway in StarPanel
2. Document Pathway and Phase in HED
3. Create 2-3 Priority Problems (HED)
Notice that the cervical surgery pathway does not
have a preop phase so pick the best fit – Day of
Surgery since the pt is going for surgery tomorrow.
Select & Save Pathway (StarPanel )
 Document Pathway Name & Phase (HED)
 Create 2-3 Priority Problems (HED)

Admission
Select & Save Pathway (StarPanel )
 Document Pathway Name & Phase (HED)
 Create 2-3 Priority Problems (HED)

Admission
Before doing anything in HED, think about the 2 or 3 Priority Problems
for Mary Lou. Review the CCC definitions as needed.
Definitions
located in
“links”
from HED
Place a check mark next to them
on “Standard Nursing Problem
List”
Document Priority Problems in Plan of Care Tab
Note the 21
categories of
problems
Locate the 3 categories you identified for Mary Lou.
Select & Save Pathway (StarPanel )
 Document Pathway Name & Phase (HED)
 Create 2-3 Priority Problems (HED)

Admission
1.
2.
3.
4.
5.
6.
Click Start
Priority
problem
Select
problem
Denote “ may
be related
to…”
Select
expected
outcome
Type “T” for
today's date
and time or
type in
another date/
time
Save
Hover over icon
to see detail
of problem.
Problem Screen works like IV Manage, Foley Catheter & Wounds.
Sample Nursing Summary
Mother of 2 young children admitted w/ surgical mass
scheduled for cervical laminectomy in am. Has weakness,
ataxia and 5/10 pain.
Sample Plan Priorities
Control pain, prep for surgery & explain post op course,
assure no falls and provide emotional support
Review Pathway & Phase - change prn (HED)
 Document expected Short Term Goals for your shift (HED)

Beginning
of Shift
In HED, type the short term goal for the shift for
each problem that will be addressed that shift.
Keep in Mind….
Day and Night shift goals
may differ.
Start/End Priority Problems - adjust Pathway & Phase prn (HED)
 Document Short Term Goal Status or outcome (HED)
 Document Nursing Summary & Plan & Priorities for next shift (HED)

End of Shift
Ending problems works the same as ending a
PIV or Foley. Select the magnifying glass,
fill in appropriate fields.
Start/End Priority Problems - adjust Pathway & Phase prn (HED)
 Document Short Term Goal Status or outcome (HED)
 Document Nursing Summary & Plan & Priorities for next shift (HED)

End of Shift
Short Term Goal
Status
1.
Hover over icon
to see detail of
goal.
2.
Document
status (met,
improving,
unchanged,
deteriorating,
not met.
Start/End Priority Problems - adjust Pathway & Phase prn (HED)
 Document Short Term Goal Status or outcome (HED)
 Document Nursing Summary & Plan & Priorities for next shift (HED)

End of Shift
Rule of thumb
between the
hours of 3 -5
to allow for
printing of OPC
for next shift
Start/End Priority Problems. Change Pathway &/or Phase prn.
 Document Short Term Goal & status (HED)
 Document Nursing Summary & Plan & Priorities in HED
 Document D/C Plan in HED & denote Post Discharge Plans to address
unmet goals

Transfer/
Discharge
Reports will be emailed to
leadership every day to
assist with monitoring
progress of staff and
patients.
Problems, expected
outcomes and the short
term goals and status.

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)

How do I choose the right problem descriptor?
Example : My pt has Heart Failure – which problem do I
pick?
Match problem closely with the interventions
If you are focusing on fluid mgmt (IV diuretics, I&O, low 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
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Keep Problem List Short &
Useable
Do make Plan Priorities
reflect priorities for the
next 12 hr shift.
Use problems started on
prior shift until significant
progress is made or the
problem has been
resolved.
Make goals/ plans specific
and realistic. Example
monitor o2 sat w/
ambulation
Review pathway and
document any changes to
pathway or phase.

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Do NOT Repeat all the
problems from the
pathway.
Do NOT replicate
standards of care unless
they are specific to a
priority problem
Do NOT include “Continue
to Monitor” unless there
are details re: what to
monitor.
Do NOT change problems
for a slightly better
descriptor.
Not all problems need be
addressed every shift –
day and night shift will
have different priorities.
1.
Print 1 high use pathway for
your areas
2.
Use the Priority Problem
Assessment tool to identify
5 common problems for this
pathway.
3. Complete the Sample plan of
care exercise for these 5
problems.
4. Identify a plan to complete
other 9 pathways sample
plan of care or your area.

Live Date: Tues
Training
Plan:
90% of Staff Trained by go live
Small groups will have opportunity to practice and ask
questions
Everyone needs to practice before go live
3-4 terminals will need to be identified to setup with priority problems in HED
train… get those terminal IDs to your SSS person ASAP.
Add to the practice scenario, a scenario for your patient
population.
Resources:
◦Priority Problem Resource Manual
Top 10 pathways for unit
Example of 5 common problems
◦Super Users/ Educator
Need enough super users for each shift
Implementation
Support
Super User 9a-5p and 9p-5a Tue- Friday
SSS 9a-5p and for 2 hours between 9p-5a Tue- Friday
Complete
10 Top use Pathway and 5 common problems
exercise (suggested to involve super users)
Complete
Sample Plan of Care exercises
Complete
Training Plan ( including recruiting super users)
Identify
3-4 terminals to set up for practice and get terminal
IDs to your SSS rep
ASK QUESTIONS