The Nursing Care Plan Defining Approach Methods

Nursing care plan helps the nurse for deciding the right approach in caring for the patient during the stay of the patient up to the time the patient is discharged. The nursing care plan becomes a written document. It is up dated from time to time, depending on the status health of the patient and incorporating any changes required. It can mean addition of some thing or elimination of some thing from the previous planned care.

Nursing practice needs thoughtful and focused planning of the care of the patient based on the laboratory investigation records and history of the patient and from time to time checking the progress made in the light of anticipated goals.

The Principle Underlying the Approach:

The basic principle about each Nursing care plan is it’s specific customization for each patient and can not be substituted by a stereotype plan of a particular disease. When there is proper nursing staff ratio in the health care set up, the nurse gets ample time to do the desk job of patient care planning and complete the records of the patient from the stage of admission to discharge of the patient followed by a home care plan based on the history, medical records, physical assessment and nursing diagnosis. The patient shall be performing care at home as suggested by the nurse either by self or with the assistance of a help.

But in practical situations, the right nurse patient ratio is never present. The night shifts are overstressing hardly any time to plan and write any thing. Writing a comprehensive nursing care plan requires lot of time. One tries to take help of the standard care plans instead of making a comprehensive nurse care plans. Standard care plans, software generated plans and plans copies from care plan books are just the resources for reference and are not substitutes for comprehensive nurse plans.

The Lacuna Needing Correction:

Comprehensive patient care planning although very vital; often is neglected as wastage of time and considered a futile exercise, thus neglecting an activity on which shall depend patient’s health. Nurse care plan is like a guide post in patient’s healthy recovery, from which all the health care workers seek guidance from time to time patient is admitted in the hospital.

The nurse care plan is left at the discretion of the nurse in-charge of the patient care. Thus other members of the health care team belonging to different disciplines get excluded. The nurse becomes overloaded with work affecting effectiveness. Patient care planning should be a joint effort in planning and executing the plan.

The patient care plan begins with correct assessing considering all the factors. When the patient is in acute condition the initial care plan should be thoroughly assessed at the time of admission and subsequently reassessment is required to be done with the changes in the status of the patient after admission till the condition of the patient gets stabilized.

Different Situations & Appropriate Plans:

When the patient requires long term care, the assessment and formulating of the nurse care plan, is based on the Minimum Data Set. In the case of home patient care nurse, uses oasis assessment plan. In other situations there are protocols on the basis of which the assessment is made and patient care plan devised and reassessment is carried out as specified in the protocol.

Having arrived at the first assessment, problems are listed, which is just simple process or one can involve Resident Assessment Protocol and minimum data set. While listing the problems one also include the strengths, the patient is having or even relations with his other family members, which are causative factors for the disease and general well being of the patient.

Finding Answers from Questioning:

The next stage is looking at the specific problem and the step poses a question in the mind of the nurse “is the problem going to be corrected or some thing can be done to reduce the intensity of the problem.” The yes answer means making a goal for resolving the problem or attempt it’s improvement during the review period, which shall be of longer duration in long term and home health care plan in comparison to acute patient’s nurse care plan . The Goal has to be specific with defined parameters of measuring the progress and achieving visible improvement.

If the problem presented by the patient has very uncertain chances of improvement, the next thoughts are can the worse progression be arrested or delayed? Such a situation is usually found in diabetic and congestive heart failure patients. The question is can an intervention minimize the problem although marginally.

Care Plan of Terminally ill Patients:

In case the problem in any manner can not be improved and the worse is imminent, what can be done to improve the quality of life till the patient is living. The examples are of Alzheimer’s disease or nutritional issue in case of terminally ill patients. The nurse care plan is till the patient is admitted in the hospital or after discharge at the home is convalescing. In case of terminally ill patients all angles and probabilities should be studied before drawing nurse care plan focusing on what comforts can be accommodated because, it is going to remain in implementation stage till the end of the life of patient.

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Josiah Macy Jr Foundation Enhancing Doctors-Nurses Education

Case Western Reserve University’s forthcoming students operated Saturday Free Clinic likely to be commence service in 2011 for the benefit of Cleveland’s poorly served people in addition to the services shall serve as training platform for nurses and doctors yet to be qualified during their education continuation giving them ac chance to become partners in patient health care. The Cleveland Free clinic shall be on the basis of cooperation between the doctor & Nursing students and community sharing the resources of the community.

The Clinic is under the project named “Inter-professional Learning Exchange and Development Program” (I-LEAD) situated at Case Western Reserve University’s School of Medicine and Frances Payne Bolton School of Nursing, which are recipients of about $640,000 funds granted by Josiah Macy, Jr. Foundation. The project satisfies the objectives of the foundation i.e. for improving education standards of health professionals keeping in view the public health standards improvement bringing noticeable changes in healthcare delivery programs.

The impression and feelings of Daniel Ornt., at the School of Medicine about the project are “The Grant funds shall be responsible to induce favorable changes in the healthcare practices besides creating services, the participating doctor and nursing students shall realize how professionals are thinking and functioning in various capacities and shall inculcate in them the virtues of team spirit.”

Ornt. and Patrica Underwood; shall be steering the project for duration of four years, besides Weatherhead School of Management shall be participating to carry out analytical work for the project and support the participating teams to get meaningful cooperation.

Underwood stated that there is necessity of creating an atmosphere where the nurses and doctors learn cooperating among each other as team members from their early education period resulting in desired changes in the healthcare delivery improving the healthcare quality.

The grant is based on the funds received by the University and is a step in the direction of forging together medical and nursing education. As pre-preparation the nursing and medical students have begun taking part to improve their communication capabilities in simulated conditions of interaction with patients in the seminars, so that they practice what they shall be doing?

Leading Healthcare organizations like World health Organization, National League of Nursing and Carnegie Foundation have called upon other organizations for increasing the inter-professional collaborative efforts to bring revolutionary changes in health care delivery in the future.
“Simply teaching inter-professional practice is not enough” it is felt by Underwood, The actual experience shall determine how and what they practice in real situations.

With the help of the granted funds the curriculum of the two related schools has been increased which shall offer favorable ground for exchanges between medical & nursing students. The objective of the Foundation and Case Western Reserve is for creating inter-professional cooperation oriented education models for implementing in other schools through out the country. The poorly served people of Cleveland shall be directly benefited by the doctors and nurses available to look after their acute and chronic health diseases besides learning concepts of healthy living and prevention of disease.

I-LEAD Program has five distinct parts, creating environment of realty based experiences within the school curriculum.
• When the group is small the experiences can be felt closely bringing nursing and medical students to find solutions participating jointly.
• Simulated patient conditions, besides other learning opportunity together for 2 to 4 hours helps in focusing at communication skill for enhancing patient safety and better outcomes.
• A community laboratory near Cleveland or in the school shall support the needs of promoting health and prevention of disease related to students studying in middle classes.
• Having Laboratory within the healthcare environment shall help the professional students experience simulated to the working of a general hospital and shall be useful to them, when they work in a general hospital.
• The students operated free clinic and laboratory having association with their respective schools within this project shall be among few such laboratories existing in the country.

The Project is part of a national movement with the objective of laying foundation of improvement oriented changes in healthcare of the past through doctor and nursing students.

“All the patients and their relatives shall have the advantage of the changes being attempted” as Stated by Underwood.

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Home Health Care Health Help & Professional Services

There are many options to choose from to get the services of a home health care giver, depending upon the health status of the person and personal needs of service.

Non-certified Assistant Help:

Non-certified assistant looks after the safety aspects of an old person, who has some ambulatory disabilities. He is engaged as helpers for long-term personal care and support services. The duties of such helpers are not restricted for personal care they also help in housekeeping, cooking of meals besides companionship to the old person. There is lot of mix up of the duties.

These services are arranged privately and not eligible for reimbursement through Medicare and private health insurance irrespective of the fact that the non-certified helper is employed with a non-medical home care organization or is hired privately. Few long-term caring insurance plans are covering such services but it is required to check with the insurance service provider. Non-certified assistants is capable of providing common routine personal caring assistance, which are usually required for helping care for a near and dear at home.

These non-certified assistants also carry out light household work of laundry wash, general cleaning of house and washing of windows. Companions also require necessary training and are not permitted direct personal care, but can be helpful in providing comfort and companionship for persons not to be left alone and unlooked after.

Certified Nurse Assistant (CNA) / Home Health Aides (HHA)

Certified Nurse Aide or CNA and Home Health Aide (HHA) are vital component of Home Health care team, and as provided in their certification conditions work under the supervision of a Registered Nurse and Rehabilitation therapists depending upon the need of the individual. Both CNA and HHA have undergone  training and certification processes, theoretical and practical examinations which vary from state to state and re-certification is required within 24 months to keep the validity continued. Some states prescribe additional training in homecare for HHA’s.

The CNA’s and HHA’s find employment with Home Healthcare and non-medical homecare organizations. The expenses on account of using CNA or HHA services are reimbursed subject to fulfillment of certain stipulated conditions like working under supervision of a licensed medical health professional besides the authorization support of the physician for undergoing these additional skilled services at home. Engaging privately paid CNA or HHA hiring is good option in situations not requiring skilled care.

CNAs and HHAs give assistance to patients requiring services of daily living activities (ADLs) which include personal caring, ambulatory support, nutrition caring, administration of medicines, toilet assistance; health issues like blood pressure measuring and record keeping and in few cases light housekeeping. The certified assistant must possess the skills of actual procedures and also keep a tab on patient’s health condition observing and communicating to supervising professionals.

CNAs and HHAs are CPR certified and depending on their level of training with state regulated variations, provide extra bedside care including wound / bedsore treating and dressing change, tube feedings, catheter insertions, and diabetes monitoring with the supervision of a Registered Nurse (RN) or Licensed Practical Nurse (LPN).

Licensed Practical Nurse:

A LPN or LVN they qualify specified curriculum and pass the National examination after completing college course for receiving their nursing license. They possess the training experiences and qualifications for performance of nursing skill procedures and are required to work under registered Nurse Supervision or a physician.

Registered Nurses (RN)

Registered Nurses (RNs) have undergone higher nursing courses and training in nursing education needed to become a Registered Nurse and pass national level examination after they finish college course for getting their nursing license. They have achieved competence for performing all facets of skilled nursing care besides supervision of other participants in the health services like LPNs/ LVNs, CNAs, and / or HHAs.

Roles of Physical Therapy/ Occupational Therapy / Speech Therapy:

These are therapies are provided by professionally qualified persons  specialization in respect of caring for physical disabilities suffered by patients due to aging or disuse of the limbs during trauma treatment. Speech Therapists and Occupational Therapist use their specialized knowledge in identifying the problem and devise treatments for rehabilitating the patient so that they come back to near normal condition after exercises and practicing the treatment advised. The objective of the therapists is improvement in mobility, strengthening of weak senile muscles, maintaining proper balance and better communications in patients suffering with speech impediments.

Social Workers (SW) / Medical Social Workers (MSW)

Social Workers are members of the health team and do house visits in certain urban or rural areas and evaluate social, emotional and environmental factors, which affect the sick and disabled persons. They get the opportunity to carry out family or individual counseling for persons who are struck up and are not able to resolve their problems without the help of guided counseling to the family members as a whole instead of the individual person. Medical social workers are the appropriate persons having knowledge and ability to resolve domestic issues affecting the health of an otherwise healthy person. They identify and search for community resources to arrange their help to the affected family.

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Law Suit against Illinois School of Health Careers

The case is of Denise Parnell, a very young single mother, who joined roughly a year ago, a course titled patient care technician program, which the school promoted for helping the students to become certified nursing assistant at School of Health Careers, a for-profit school, situated in Illinois. The said course is just going to be completed. On 2nd June in one of schools letter made known to the students that they shall not be in a position to take the test of CNA, because the course is not approved for the state of Illinois.

Denise Parnell is living with her aunt. To carry on her education she had secured loans worth $13000 out of which $8546 is the Federal loan. This all led to wastage of money as well 1 year time.

Consequently Parnell and three of her classmates have filed proposed class action suit against the school for mis-representing the Patient care technician course. Rising to the occasion, Illinois State Board of Education has taken up the investigation.

Glaring lapse has taken place at a time, when there is lot of criticism stressing strict regulation for profit schools, which entrap low income students, who go further down on debts with degrees of questionable value and utility to them.

In contrast supporters of for Profit schools claim their courses a source to students for accessing higher education and vocational learning through their trainings. The US Department of education such schools to make disclosures in respect of job-placement rates, student’s debt data and their income.

Allegations & Responses:

At the time Parnell got enrollment in this school of Health Careers at Illinois, she along with her other classmates received school published material, which had very clearly mentioned that after graduating Patient Care Technician program of the school, shall be in a position to take the State Board Examination for becoming a Certified nursing assistant.

US Senator Dick Durbin and others associated with law drafting asked for a report on for-profit schools regarding the standard of these school teachings as well as to what extent the federal revenues are used in these institutions as student federal aid.

On 2nd June, 2010 the President of School’s parent Company, Forefront Education informed the students and the faculty of the school, communicated that some school staff had committed error and labeled this as “Unauthorized wrong information”.

The mistake has been accepted and apology expressed by the parent school president and stated that the matter does not end with just an apology and still said that the best efforts shall be made that the students can take the CNA examination.

The above letter has also proposed to the affected students to attend a certified Nursing Assistant course at Chicago and the school shall pay the expenses besides additional $1500.00 to cover any unanticipated cost in this respect.

At the same time the Illinois School of Health Careers stated that their patient care technician course was not designed for becoming CNA.

A further explanation by the Parent Company President about the objective of the course mention the course to be of 8 months duration, formulated so that the students after graduation get entry of working in nursing homes or any health care facility, where one shall be taking care of the patient, who are themselves not in a position to take their care.

IDPH has not recognized the qualification of graduates of the school as Patient Care Technicians for directly caring for the patients in nursing homes and long term caring in nursing homes and hospitals.

The fact is that The Illinois School of Health made an application to IDPH for approval of the course for Certified Nursing assistant in the month of January, 2010 after 6 months from the commencement of the course. It is stated by the Company President that the application was made on the insistence of the students studying the course.

Parnell has filed a law suit in Cook County Circuit Court and many other students have also joined her. The problem of miscommunication has taken very wide dimension effect on the course.

The Illinois School of Health Careers in their published catalog of 2009 academic period have categorically stated that students enrolling in Patient Care Technician course shall get the training to perform basic patients caring techniques, which are needed by Certified Nursing Assistant and shall be qualified to work as nursing assistant.

The State Board of Education had sanctioned the patient care technician course in the year 2007 during the month of September. The school did not start implementing the course and admission of students before June 2009. The school after commencing the course has been admitting 30 students every month.

Further it was responsibility to in the mean time obtain approval from IDPH. The two different organizations approving the same course can leave certain gaps, which can be misunderstood or misrepresented.

The plaintiffs in this lawsuit have claimed $5 million from the school for tuition, expenses incurred and loss of time in remaining in the course. It is estimated 350 students are affected by this glaring lapse on the part of school authorities.

In case the State Board of Education’s looking in to the matter comes to the conclusion of wrongdoing, this can result into sanctions and warning the school, suspension of Patient Care Technician Course and the school shall be on probationary status or revoking of school’s earlier approval.

The present of the Parent Company of the school stated that corrective steps have been taken and now the school staff is telling the new incoming students beforehand about the true position.

Further the president of the parent company has stated that the communication has been sent to the concerned persons that they are going to resolve the situation and help the student to be successful in their careers.

The Career College Association representing 1600 schools for profit blamed the press for their views in respect of growing industry of for profit schools although there are some bad instances for which the concerned school and students hold some responsibility.

Gazing at the few spent balloons on the mother’s day Parnell had tears in her eyes and was not in a position to console her. She was very passionate to become a certified nursing assistant this year.

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History behind Origin of CNA Training

The rules pertaining to cna training follows with the enforcement of Omnibus Budget Reconciliation, Act of 1987 (OBRA 1987), according to which the State Approved CNA training and courses should be of  minimum 50 hours of theory and 100 hours supervision supported clinical training. The candidates who do full participation in the program as specified by the specific states and after they pass the theoretical as well practical clinical competence test, they are called as CNA and their name is included in the state Registry. The certification is valid for 24 months and during the validity one has do the recertification.

There are specified basic skills, which the CNA must be in a position to perform, which are required while working in long term health care facility or in the home surroundings of a patient relate to caring for elderly patients and the same apply to general CNA patient care also.

Eligibility for CNA Training:

A person who holds 10th grade diploma or GED qualification is eligible to join the CNA training school the training program of which has to be approved by State Health Board. The Training school employs experienced Registered Nurses and Medical Assistants who design and formulate the course complying with the State Health Board specifications.

The CNA Training Schools:

The entry level to Nursing Profession is first to become a CNA. To impart the training to the candidates enrolled with the training school training schools are established through out the state run by vocational colleges and community colleges besides other University affiliated colleges. These schools have class room settings to impart theoretical studies and Laboratories where the students have an occasion to learn the practical aspects of CNA training. Normally the training schools impart 75 hours to 100 hours training depending on the state stipulations.

CNA Online Training:

There is provision of online training, where one can complete the training at one’s own pace. There are virtual laboratories where the candidates can have clinical experience. The online training also has to be approved by the State Health Board, which is state specific only. Before joining an online training course one must check with the state Health Board regarding it’s approval for the state.

One has to have clinical experience at a real time health care facility, by working as a volunteer.

CNA Competence Test:

All the candidates undergoing CNA training through regular colleges or through an online provider has to undergo theoretical as well as practical competence test. After passing this test name of the Candidate appears in the State Administered registry and one can now work in a hospital or any health care facility.

Providing Physical & Emotional Support:

Certified Nursing Assistant (CNA) performs the primary role in looking after the physical and emotional needs of the persons admitted in a healthcare facility for treatment of their disease by working under the supervision of a Registered Nurse (RN). CNA is also known by many different names like Nursing Assistant Certified, Patient Care Assistant, State Tested Nurse Aide or Nursing Assistant Registered, depending upon the patient health care organization, where one is working. All of them pertain to popularly known term CNA. The functions of a CNA range from Activities of Daily Living (ADL), bed side caring and basic nursing functions performance.

The place of CNA in a health care team is very vital. The CNA may be having lot of experience, but still depends on RN and Doctors for their supervision and in turn they depend on CNA for execution of the treatment advised to the patient. This is so because his CNA Certification is subject to the supervision of RN, because CNA experience is not supported by requisite qualifications and there can be legal as well liability issues in the event of a CNA overstepping over and abive what he or she is not supposed to do.

The Present day Healthcare facilities:

In the present day functioning of hospitals or long term health care facility the CNA has a specific and vital role, besides other workers, who hold higher qualifications and authority in the set up. A CNA is required to perform routine jobs, where the qualifications do not matter and thus spares the Registered Nurse performing function, permitted under the State Nurse Practice Act in respect of formulation of care plan, assessing the results, administration of medicines besides preparatory assistance in the surgery room.

On the other hand a CNA is required to possess the skills of performing the nursing functions assigned besides observing the state of health condition of the patient in respect of respiration rate, blood pressure etc. In case of an abnormal finding the registered nurse is to be informed to take over the care requiring her intervention.

The CNA is paid an average salary of $11.14 per hour and maximum being $23.16 per hour.

The routine Functions of CNA is among the following tasks:

  • Attending to Patient’s calling.
  • Bed confined patients are helpless and from time to time their position is required to be changed for prevention of development of bedsores.
  • Necessary observation of patients’ status by measurement of and recording food and liquid intake and urine output and other vital signs, and bring to notice the observations to supervising staff.
  • Assist patients in their locomotion, performing advised exercises, and helping their movement in and out of bed.
  • Providing patient care in dressing the wounds if any and supervision in exercising schedule.
  • Preparing patients undergoing surgery, specialized treatment, or consultant examinations.
  • Transporting the patients to treatment units with the help of a wheelchair or stretcher trolley.
  • Cleaning of room and changing of linens.

It is required that the nurse assistant should also possess excellent practice in conducting emergency procedures and maintain calmness, when the situations are stressful.

The option of continued education online is very useful to the Certified Nursing Assistant to enhance learning in part time by enrolling for Bachelors degree in nursing course and after few years complete the degree course and qualify for Registered Nurse and still further to Doctorate Degree in nursing.

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