Nursing Care Plan in Picis

Now that you’re getting comfortable with
charting in Picis…here are some more
details regarding our new method of
documenting the nursing care plan….

What is it?
„ The nursing diagnosis flowsheet in Picis is where
we document our “plan of care”.
„ The guidelines we need to follow for this include
{ Include families in this plan of care (let them know what
we are working towards)
{ Initiate at least one applicable nursing diagnosis within 24
hour of admission
{ Review and document the “outcome evaluation” once a
day
{ Review entire plan of care weekly (Mondays by 2200)

They were selected based on important aspects of care for NICU patients. .NICU Care Plan There are six categories pre-built into this flowsheet.

a set of “outcome indicators” or goals in the third row and an outcome evaluation tool in the last row. a set of related factors in the second row.NICU Care Plan Each section has a set of nursing diagnosis in the top row. .

Some patients may have more than one. You can select the most appropriate nursing diagnosis or problem from this list. The nursing diagnosis are lists of problems or potential problems that the NICU patient may have. .NICU Care Plan – Nursing Dx.

NICU Plan of Care–Related factors Related factors are possible “causes” for the patient’s problem .

.NICU Plan of Care – Outcome indicators The “outcome indicators” are goals. You select one or more goals that are applicable to the patients entire NICU stay.

select a rating for the severity of the problem. . but eventually get to a 4 or 5 upon discharge. A patient may start out with the problem’s outcome evaluation being a 1 or 2.NICU Plan of Care – Outcome evaluation Upon initiating the nursing diagnosis.

the outcome evaluation or problem score must be reviewed to determine if the patient has progressed or regressed with the nursing dx or problem.NICU Plan of care .review Once daily. . (NICU is schedule for 0300).

NICU Plan of care . „ This is done using input from multidisciplinary rounds. family and your nursing assessment of the patient.review „ Once a week (we have selected Monday by 2200). the entire plan of care must be reviewed and updated. .

Common NICU Nursing Dx. Thermoregulation .

Nutrition ..

Common NICU Nursing Dx. Skin .

Common NICU Nursing Dx. Immune system - infection .

Common NICU Nursing Dx. Infant behavior - development .

„ Coming soon: Alterations in newborn parenting „ There are additional Problem/Nursing Dx in the protocols. { Bereavement. These may apply to your patient’s special needs.Common NICU Nursing Dx. Neurological . Knowledge { GI. Communication { Cardiac.

.

Parenting This generic “parenting” P/ND may work for your plan of care until we get the neonatal parenting P/ND added .

. you should have the Immune family included in your plan of care).NICU Plan of Care „ The care plans that are done look very good. if your patient is on antibiotics. „ Continue to use these to document your nursing plan of care „ It is important that these coincide with the medical plan of care (ie.

please let Stephanie or Janet know.NICU Plan of Care „ If you would like more nursing diagnosis added to better fit our patient population. Review Test .