A Review for development of Concise Nursing Care Plan (CNCP)

 

Shrikant Desai¹, Ravin Kumar Bishnoi², Shivani Devi³, Anisha Rukadikar⁴

¹Senior Nursing Officer (Quality Control), All India Institute of Medical Sciences, Rishikesh.

²PhD Scholar, Centre of Excellence for Nursing Education & Research, All India Institute of Medical Sciences, Rishikesh.

³Nursing Tutor, Centre of Excellence for Nursing Education & Research, All India Institute of Medical Sciences, Rishikesh.

⁴Registered Nurse, Musgrove Park Hospital, NHS Foundation, UK.

 

ABSTRACT:

Historically, nursing care plans were administered in academic field to teach a process that nursing students can use it to identify and define a patient-centred problem. Nursing process has evolved to a five step process which includes assessment, diagnosis, planning, implementation and evaluation. But it has been observed that nurses are not following all the steps of nursing process because of one or other reasons like inadequate knowledge regarding nursing process, heavy workload, staff shortage, lots of paper work, poor quality of professional education, lack of motivation and unplanned early discharge. Nurses are not developing care plans on the basis of patient’s needs, they are just providing care which has been prescribed by the doctors and not focusing on nursing care plan. Whereas, it is an essential document to maintain record. The impetus of this review is to improve the utilization of nursing care plan by making it less time consuming, less paper work and reduces the workload of nurses. So, nurses can change their attitude and start utilization of nursing care plan for providing better care to the patient. This concise nursing care plan (CNCP) includes all the steps of nursing care plan and reduces more writing work making it easy to follow.

 

 

 

INTRODUCTION:

The active participation of patients in health decision-making is a core concept of patient care planning which advocates the rights of the patients⁽¹⁾. The patients involvement in their care planning, decision making and self-care concept can be brought together by nursing care process⁽²⁾. Development of individualized patient care plans are considered as a routine part of nursing care⁽³⁾.

It is an important part of nursing documentation, which is considered as an important indicator to develop nursing care⁽⁴⁾. As nursing being recognized as a profession, the discipline has started to establish its own conceptual and theoretical framework and, of them, nursing process is the peculiar one⁽⁵⁾.

 

The introduction of nursing process as a systematic and scientific approach to patient’s care started in the early 60s in the developed countries⁽⁶⁾. The nursing process is being defined as a systematic, organized, and dynamic way used by nurses to meet the individualized healthcare needs of their patients through operating five interrelated steps: assessment, diagnosis, planning, implementation, and evaluation^(7)(8)(9).

 

Figure 1: Nursing process model.

 

During academic training in nursing school, writing nursing care plans was best way to learn the nursing process. But practicing nurses are hardly write these lengthy nursing care plans in clinical settings and  don’t value such plans, and the Joint Commission hasn’t required them for more than a decades⁽¹⁰⁾.

 

IDEAL NURSING PROCESS MODEL:

The nursing process model (fig 1) is a structured, problem solving approach to nursing practice and its evaluation. This is first described by Yura and Walsh in 1967⁽¹¹⁾. This process containing five steps: assessment, diagnosis, planning, implementation, and evaluation. The nursing process model is a central and widely accepted concept both for nursing practice and documentation⁽¹²⁾. The primary purpose of the model is to provide individualised comprehensive nursing care to individual patient, not the generalised routine care.

 

PRACTICE OF NURSING CARE PLAN IN CLINICAL SETTINGS:

The nursing process has been the target of discussion and research as a nursing care instrument to be taught, used (in clinical practice besides nursing management) and assessed⁽⁶⁾. Many studies show that in practice, application of the nursing process is not well developed. Most of the nurses are either not at all practicing nursing care plans or not following all the necessary steps (assessment, diagnosis, planning, implementation, and evaluation) of nursing care plans. Nurse’s attitude towards writing nursing care plan is also not favourable^(9)(13)(14). Many reviews and studies result suggest inadequacies in almost all areas of nursing documentation, with only one in five nursing care plans capturing the patient’s needs in their clinical audit⁽¹⁵⁾. It is a matter of concern that practicing nurses don't appraise individualized care plans. Almost, in 95% of hospitals in India, nurses just act as subordinates to the physicians and carry out only physician’s plan of care, furthermore, the nursing care planning is not consistently performed in any of the organizations⁽³⁾.

 

Authors have also seen that Indian nurses are either not practicing the nursing care plan specially in government sector or they are practicing incomplete and haphazardly which are not including all the required steps of nursing process because of one or another reasons such as overburdened with the patients and other managerial responsibilities.

Barriers of executions of nursing process from Nurses’ Perspectives:

·      Knowledge level of the nurses is one of the most determinant factors for application of the nursing process. Miskir Y, 2018; Mahmoud M, 2016; Pokorski S, 2009; Hagos F et al, 2014; Atnafe G, 2017^{(5)(6)(9)(13)(14)} reported that about 50-90% of the nurses have poor knowledge about nursing process and its steps.

·      Lack of experience of writing nursing process^(5)(6)(16).

·      Negligent work place⁽¹⁴⁾.

·      Staffs are not able to follow the Patients due to unplanned early discharge^(5)(14)(16).

·      Heavy workload & staff shortage: Excessive number of Patients and tasks assigned to the nursing team and inadequate number of staff lead to lack of time to implement nursing process^{(5)(6)(9)(16)(17)}.

·      Nursing process requires tedious (too long) documentation making it time consuming^(9)(16).

·      Lot of paperwork⁽¹⁷⁾.

·      Lack of specified nursing care document⁽⁶⁾.

·      Poor quality of professional education⁽⁹⁾.

·      Enabling and Reinforcing Factors: Most of the enabling and reinforcing factors did not motivate nurses to apply nursing process^(5)(13).

·      Inability to individualize patient care, lack of interest in its use in patients care, lack of cooperation among nurses^(6)(17).

·      Resistance to change, Rigid mindset, Practice guided by tradition, Habit, Routines, stereotypical perceptions of clients, Fear of making mistakes, Unwillingness to take risks or look for alternative strategies, Decision making without sufficient data or supported by rationale, Failure to evaluate effectiveness of nursing actions⁽³⁾.

·      Insufficient equipment for the implementation of nursing process^(16)(17).

·      Absence of in-service training pertinent to nursing process⁽⁵⁾.

 

NEED FOR REFORMING THE NURSING PROCESS IN A CONCISE MANNER:

Various studies have reported poor practice of nursing process in clinical settings especially in public sector hospitals because of variety of barriers which hinders the utilization of nursing process such as lack of time, overburdened working environment, lengthy documentation of traditional methods of nursing process, lots of paperwork and lack of specified nursing care document etc. Nursing process is an essential document to maintain the record of nursing care provided to individual patient. To improve the utilization of nursing process in day to day routine of nursing care there is ardent need of development of more specified and concise nursing process, which will include all essential care aspect and consume less time and paper work. 

 

DEVELOPMENT OF CONCISE NURSING CARE PLAN (CNCP):

This concise nursing care plan (CNCP) has been developed after extensive review of literature regarding utilization of nursing care plan, barriers or factors influencing practice of nursing care plan in hospitals. Search strategies have been developed and relevant researches identified from databases including PUBMED, CINHAL, and Cochrane library and published or unpublished grey literatures. After initial development, opinions shouted from experts of nursing fields and nurses’ working in various public and private hospitals settings and designed concise nursing care plan as per current needs and applicability.

 

DESCRIPTION OF CONCISE NURSING CARE PLAN (ANNEXURE 1):

Nursing care plan provides direction on the type of nursing care to the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. A care plan includes the following components: assessment, diagnosis, expected outcomes, interventions, rationale and evaluation.

 

This Concise nursing care plan starts with quick assessment which is very basic for critically ill patients and rest of the care plan includes common parameters, assessment part, diagnosis part, planning and implementation part and evaluation part.

 

Part I Quick assessment:

Vincent JL (2005) described and published the FAST HUG mnemonic to identify and check the key aspects in the general care of critically ill patients admitted in the Intensive Care Unit (ICU)⁽¹⁸⁾. Later, Hatton; WV (2009) updated the mnemonic by adding few more components to FAST HUG mnemonic thus reframing it to FAST HUGS BID. As per this “FASTHUGSBID” is a reference checklist to assess the existing condition and interventions of patient ,in this checklist nurses are need to tick [√] wherever applicable⁽¹⁹⁾.

 

 

Part II Concise nursing care plan:

1.    Common parameters:

In thisConcise Nursing Care Plan (CNCP) common parameters are the observations, which are applicable for most of the general ward patients as well as critical care patients. We have created total 10 numbers of designated parameters commonly for all kind of patients and also given a provision for writing any parameter other than these 10 common parameter if needed.

 

These parameters include:

a.    A(Airway), B(Breathing), C(Circulation)

b.    Pain Assessment:

In our CNCP we used Wong-Baker FACES^® Pain Rating Scale. There are 6 faces in the Wong-Baker Pain Scale. The first face represents a pain score of 0, and indicates "no hurt". The second face represents a pain score of 2, and indicates "hurts a little bit." The third face represents a pain score of 4, and indicates "hurts a little more". The fourth face represents a pain score of 6, and indicates "hurts even more". The fifth face represents a pain score of 8, and indicates "hurts a whole lot"; the sixth face represents a pain score of 10, and indicates "hurts worst⁽²⁰⁾.

c.    Hygiene:

This parameter will express the need of hygiene for consciousness and unconsciousness patients including Glasgow coma scale to define the level of unconsciousness.

d.    Nutrition:

Good nutritional status is crucial in all the age group to maintain optimum health; this parameter is focusing on needs of nutrition in aspects of patient condition and tolerance.

e.    Pressure sore:

In this CNCP, we incorporated “Braden risk assessment tool”. This is a clinical tool you can use to assess risk of a patient/client developing a pressure ulcer. Use this together with your clinical judgement. The primary aim of this tool is to identify patients/clients who are at risk, as well as determining the degree of risk of developing a pressure ulcer. The Braden Scale is a scale made up of six subscales, which measure elements of risk which contribute to either higher intensity or duration of pressure, or lower tissue tolerance for pressure. These are: sensory perception, moisture, activity, mobility, friction, and shear. Each item is scored between 1 and 4, with each score accompanied by a descriptor. The lower the score, the greater the risk. Individuals with a total score of 16 or less are considered at risk⁽²¹⁾.

f.     Visual infusion phlebitis score:

The Visual Infusion Phlebitis score is a very popular tool for monitoring infusion sites. Infusion phlebitis originates from two main sources. One is mechanical the other is chemical. By far the most prevalent cause of infusion phlebitis is chemical in origin. Early recognition of phlebitis will help to maintain patient safety and comfort and also determines the appropriate discontinuation of peripheral intravenous catheters as per identified objective scoring mentioned in the CNCP⁽²²⁾.

 

g.    Elimination needs:

Some of the factors that impact on urinary and fecal elimination and place patients at risk for impaired elimination. This parameter will express the how the elimination needs are identified and managed accordingly.

h.    Sleep:

Sleep is a dynamic and essential part of hospitalised patients, nurses are strategically placed to promote sleep and sleep health. In this regard, nursing actions should be based upon effective methods of assessment of patient sleep. In CNCP assessment includes normal sleep and insomnia.

i.     Fear and anxiety:

Most of the hospitalised patients are having fear and anxiety about their existing disease condition and treatment regimen. In this parameter, as a nurse it is very important to determine your patient’s level of anxiety and fear.

j.     Any other:

This open space can be utilized to write the special finding parameters which are not listed from “a toi” parameters.

 

2.    Assessment:

Assessment is an essential component of nursing process and practice, required for planning and implementation of patient and family centred care.

 

ABC assessment: In this CNCP the assessment would be made by Underlying/ticking [√] the options as per subjective and objective findings of patient from pre-defined parameters.

 

Case scenario for ABC assessment:

Mrs Laxmi is a 65year old woman, has a chest infection and is breathless and chesty. She is on oxygen (O2) 40%. In addition to bronchodilators, the doctor has prescribed saline nebulisers six hourly to lower the viscosity of the secretions and aid expectoration of her sputum and her BP is normal.

 

As per this case scenario nurse documents in CNCP (Table 1) as per priority needs, firstly she finds airway disturbance due to viscos secretion, here nurse underlines the SECRETION assessment by pen and acknowledges its presence by ticking [√] and on breathing assessment she was on oxygen 40% then nurse underlines on REQUIRED O2 option and acknowledges by ticking [√]. Then on assessment of circulation, nurse finds no pallor, normal BP, no oedema and normal output, here the nurse underlines BP NORMAL acknowledges by ticking [√].

 

Table 1: Illustration for ABC assessment

Parameters	Assessment	Tick as per need [√]
ABC A-airway   B-Breathing   C-circulation	A-Check Airway for clear / Secretion /Any obstruction	[√]
	B –Maintain in room air/Required O2 /Intubation and ventilation	[√]
	C-Check for / BP-(Normal/decreased or increased)/Edema/Output normal or decreased	[√]

 

In the same way of ABC assessment all other parameters such as hygiene, pressure ulcer, nutrition, elimination, sleep, fear and anxiety are underlined and acknowledged by ticking the space given against each assessment column as per subjective and objective findings, but when assessing pain and visual phlebitis, assessed score finding is directly entered in space given against the respective assessment column instead of ticking.

 

Case scenario for assessment of Pain:

Mr. Ravi is a 55year old man he has a chest pain and he is breathless.

 

As per this case scenario nurse documents pain score after comparing with “Wong-Baker FACES” Pain rating scale, i.e. score found after assessment is “4” and enters the same score in score box given against assessment column (Table 2).

 

3.    Writing Nursing Diagnosis:

In this CNCP the nursing diagnosis are formed on the basis of subjective and objective assessment which are formed on the basis of pre-defined parameters. Nursing diagnosis chosen according to list given by NANDA–International earlier known as the North American Nursing Diagnosis Association (NANDA). Suitable nursing diagnosis can be entered in the space given against the assessment column (Table 3).

 

Table 2: Illustration for pain assessment

Table 3: Illustration for writing Nursing diagnosis:

 

Table 4: Illustration for writing Planning and implementation column

 

4.    Writing Planning and implementation column:

The purpose of planning and implementation is to set priorities and develop patient goals and outcomes. In this CNCP planning and implementation is written on the basis of assessment and nursing diagnosis and predicted best possible outcomes.

 

In this CNCP as mentioned below illustration (Table 4) Planning is all about pre-defined possible components developed on the basis of assessment and diagnosis, here the nurse underlines the component which is planned according to patient problem or diagnosis. For an instance if the nursing diagnosis is “Ineffective airway clearance” then planning would be suctioning, here nurse will do underlining on suctioning and acknowledges the suctioning procedure as implementation by ticking [√] in implementation column.

 

5.    Evaluation:

Both the patient’s status and the effectiveness of the nursing implementations must be continuously evaluated, and the care plan modified as needed. In CNCP outcome of implementation to be written in the evaluation column.

 

CONCLUSION:

It is well known that a nurse considers a patient as an individual. Even though many patients’ diagnosis may be same, but they have different physical, psychosocial and spiritual needs. Comprehensive nursing care can be provided by planning an individualised nursing care plan, but various researches have shown improper utilization of must needed document ‘nursing care plan’ because of various reasons. It may be of more workload, staff shortage or more paper work. This concise nursing care plan (CNCP) comprises all the necessary steps; these are assessment, diagnosis, planning, interventions and evaluation. In this CNCP, a nurse only has to tick mark [√] the necessary area. There is no need to write lengthy nursing care plans. This CNCP reduces lot of paper work, less time consuming and easy to maintain. This CNCP can be used in all areas including critical or general wards in the busy public hospitals.

 

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Received on 29.07.2019        Modified on 14.08.2019

Accepted on 27.08.2019       ©A&V Publications All right reserved