Planning station is second station in APIE
You are required to complete two critical care plans within a 14-minute timeframe in a quiet writing station. The necessary materials for this task include your NEWS2/GCS/Community Assessment chart, which was utilized during the assessment station of the APIE process.
The primary emphasis of the care plans should be on addressing the marking criteria conditions. To achieve this, carefully review the planning station scenario within the allocated one-minute period before initiating the prioritization of nursing problems. These problems can stem from either the provided scenario or the assessment conducted in the preceding station.
Typical nursing issues that often arise involve pain, confusion, shortness of breath, immobility, activity intolerance, anxiety, weight loss, and more.
In the event of an error, strike through it in a single line and affix your signature below the correction. It is advisable to complete any available spaces before commencing to prevent running out of time, such as filling in candidate and patient details, signature, date, and time.
NURSING PROBLEM
State nursing problem using SMART method ie simple, measurable, achievable, recordable and time bound.
Example, instead of ineffective breathing pattern you can write shortness of breath. In case of pain you can write headache or any other pain per the scenario.
Remember to mention the patient name instead of using ‘patient’ or ‘client’
Mr Amos is experiencing pain at the surgical site as evidenced by pain score of 8/10
Mrs Juna is experiencing shortness of breath as evidenced by respiratory rate of 23 bpm
Always after as evidenced by use data you have got from the assessment station
Patient Name + Problem + Reason
While it’s not obligatory to provide the rationale when formulating a nursing problem, doing so is considered a beneficial practice. This approach ensures that the reader gains a clear understanding of the problem at a glance.
NURSING AIM/GOAL
After writing the nursing problem, you need to specify the aim of our care plan. In other words, aim of care communicate the purpose of the nursing care interventions included in the specific care plan. This should be in future tense but measurable using pain score, observations or objective data
Eg. Mrs. Juna will maintain normal respiratory rate of 18-20 breath per minute
Mr. Amos will verbalize reduced pain 0f 3/10
RE-EVALUATION
We must align the nursing care plan with the established goal, and it’s essential to periodically reassess the care’s effectiveness within a specified timeframe for the patient. This timeframe should be clearly indicated in the ‘re-evaluation date’ section of our care plan.
When determining the re-evaluation date and time, it’s crucial to consider the following points. Keep in mind that the objective is to achieve the care goal, allowing for a re-evaluation and assessment of the care plan whenever feasible. Therefore, when setting the re-evaluation date, use today’s date as a starting point, select the nearest practical time, and remain attentive to any changes in the patient’s clinical condition.
Here you have to write “Today (date), at the end of every shift and as Patient’s clinical condition changes”
But if it’s a;
- Pain, today’s date then 30 minutes after giving pain medication or if clinical condition changes
- Mobility Related, today’s date then when the patient requires assistance or if clinical condition changes
- Community Scenario, re-evaluated in the next visit or if clinical condition changes
- All Other Problems, todays date – with every observations or if clinical condition changes
Eg. 01/01/2020, at the end of every shift and as Juna’s clinical condition changes
NURSING INTERVENTIONS
Now, let’s transition to the central aspect of the care plan, namely, the ‘nursing interventions.’ These interventions form the core of any care plan, outlining the nurse’s strategic approach to accomplishing the care plan’s objectives.
Effectively planning your care becomes more straightforward when initiating interventions using the mnemonic EMATARID – Explain, Monitor, Assess, Teach, Administer, Refer, Instruct, Document. However, the specific words utilized may vary depending on the unique requirements of the care plan. Other terms such as Explain, Monitor, Assess, Teach or Educate, Administer, Provide, Refer, Instruct, Document, etc., may be employed based on the specifics of the care plan.
Now let’s elaborate on the following key elements:
E – Explain
Explain and engage in discussions regarding all aspects of care. Obtain consent for all nursing interventions.
M – Monitor
For patients with breathing problems:
– Monitor and record observations, including respiratory rate and oxygen saturation, every 2 hours. Follow NEWS2 Policy escalation guidelines.
For neurological patients with GCS Score = 15:
– Monitor and record observations every 30 minutes for the first 2 hours, then 1 hourly for the next 4 hours, and subsequently every 2 hours until stability is achieved (GCS maintains 15/15). Escalate as per NEWS2 policy.
– If GCS <15, monitor and record observations every 30 minutes until GCS reaches 15. Escalate according to NEWS2 Policy.
For those at risk for haemorrhage:
– Monitor and record observations every 15 minutes for the first hour, every 30 minutes for the next two hours, and then every two hours for four hours. Escalate as per NEWS2 policy.
A – Assess
Assess for signs of deterioration, pain using a Pain assessment tool and PQRST – stands for Provocation, Quality, Region (or Radiation), Severity (or Scale), and Timing Method, nutritional status using the MUST Score, signs of bleeding, and the mobility status of the patient using the Falls Risk Assessment Tool.
T – Teach
Incorporate health education by:
– Educate on Smoking Cessation program or harmful effects of smoking.
– Educate on the use of assistive devices.
– Educate on Repositioning Techniques and Range of Motion Exercises.
– Educate on PFM (Peak Flow Measurement) for Bronchial Asthma Patients.
– Teach about deep breathing exercises, diversion activities, the importance of exercise, signs of bleeding, signs of respiratory distress, disease condition, and the need for drug compliance.
– Promote knowledge and understanding of the patient’s condition to the patient and immediate relatives.
A – Administer
Administer medications and monitor their effects within this section.
R – Refer
Refer patients to Physiotherapists, Dieticians, Occupational Therapists, Chaplains, Social Services, Smoking Cessation Programs, etc.
I – Instruct
Instruct on using the call bell
Instruct on not moving out of bed without assistance in cases of immobility.
D – Document
Thoroughly document all planned care activities.
Example one
Nursing Problem:
Mr. Amos is currently experiencing pain at the surgical site as evidenced by pain score 7/10
Aim of Care:
Mr. Amos will verbalize reduce pain/will be free from pain
Re-evaluation date:
Today 01/01/2020 12:30 pm or if clinical condition changes
Nursing Interventions:
Explain and discuss all aspects of care to Mr. Amos, obtaining consent for each nursing intervention.
Monitor and document observations of Mr. Amos during off-hours, calculate the NEWS 2 score, and respond in accordance with the NEWS 2 Policy.
Assess Mr. Amos’s level of pain using pain rating scale.
Teach/Educate Mr. Amos on relaxation techniques such as breathing exercises and alternative pain management methods.
Administer prescribed analgesia to Mr. Amos and assess its effectiveness after 30 minutes.
Ensure a comfortable position for Mr. Amos, incorporating additional pillows if needed.
Motivate Mr. Amos to express any concerns and, if necessary, refer to a diversional therapist.
Instruct Mr. Amos on the proper use of the call bell for assistance.
Document all aspects of care provided.
PRINT NAME: Norman
NURSE SIGNATURE: Norman
EXAMPLE TWO
Nursing Problem:
Mr. Razak has risk of infection
Aim/Goal of Care:
Mr. Razak will be free from risk of infection
Re-evaluation date:
Today 01/01/2020 with every observations or if clinical condition changes
NURSING INTERVENTIONS
Explain and thoroughly address all aspects of Mr. Razak’s care, ensuring to obtain consent for each nursing intervention.
Monitor and document vital signs at 15-minute intervals during the initial hour, at 30-minute intervals during the second hour, and 1 hourly for the subsequent four hours, following the NEWS 2 policy thereafter.
Assess for signs of infection, such as redness, exudates, unpleasant odour, compromised wound closure, and pain or tenderness.
Administer antibiotics as prescribed to Mr. Razak.
Employ aseptic non-touch techniques when conducting wound care.
Educate Mr. Razak on proper handwashing techniques and emphasize the significance of maintaining a protein-rich diet.
Encourage open communication for Mr. Razak to express any concerns he may have.
Refer to a tissue viability nurse if necessary.
Instruct Mr. Razak on the use of the call bell for assistance.
Document all aspects of the care provided thoroughly.
PRINT NAME: Norman
NURSE SIGNATURE: Norman
