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Related Concept Videos

Planning Nursing Care II01:29

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A nursing care plan can present in two forms: informal and formal. Informal is a care plan for the individual use of the nurse and goals they wish to accomplish during their shift. Informal care plans are not included in the patient chart. A formal nursing care plan is a written or computerized guide that organizes patient care. It is further subdivided into two: standardized and individualized care plans. Standardized care plans are pre-populated care plans for specific patient populations,...
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The planning phase of the nursing process helps nurses set priorities, outline patient-centered goals and expected outcomes, and tailor nursing interventions to align with the aligned care plan. Through the planning phase, the nurse applies critical thinking skills to align and develop interventions according to the patient's needs. It provides continuity of care allowing patients to receive the maximum benefit from treatment. It serves as a pilot plan for allocating individual staff to a...
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Several factors are considered while creating a patient's care plan. Motivation is a factor in improving communication, and patients often require encouragement to try different approaches involving significant change. It is essential to involve the patient and family in decisions about the plan of care to determine whether the suggested methods are acceptable. Consider meeting critical comfort and safety needs before introducing new communication methods and techniques. Allow adequate time...
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Planning for learning involves the development of a teaching plan. Teaching plans are similar to nursing care plans—both follow the steps of the nursing process. Planning in the teaching process involves setting goals and outcomes. Here, goals identify what a patient needs to achieve to understand a healthcare topic better, whereas the outcomes are the action to be performed by the patient to achieve the goal within a timeframe. For example, if the goal is to educate the patient about...
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Implementation is the execution of the nursing care plan developed during the planning phase.
The five steps to implementing effective nursing care include reassessing the patient, reviewing and revising the existing nursing care plan, organizing the resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.
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Standards of Care II01:19

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Nurses bear specific legal responsibilities under several federal statutes, including:
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Implementing a Standardized Transition Care Plan in Skilled Nursing Facilities.

Mark Toles1, Jennifer Leeman1, Cathleen Colón-Emeric2,3

  • 1The University of North Carolina at Chapel Hill, USA.

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|June 27, 2018
PubMed
Summary

A new Transition Plan of Care (TPOC) template successfully supported skilled nursing facility (SNF) staff in preparing patients for home care. The tool achieved high patient reach, staff adoption, and fidelity in transitional care planning.

Keywords:
care planning templateskilled nursing facilitiestransitional care

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Area of Science:

  • Gerontology
  • Health Services Research
  • Implementation Science

Background:

  • Transitional care strategies in skilled nursing facilities (SNFs) remain underexplored.
  • Effective implementation of care transitions is crucial for patient outcomes post-discharge.

Purpose of the Study:

  • To pilot test the Transition Plan of Care (TPOC) template as an implementation tool for transitional care in SNFs.
  • To evaluate the impact of the TPOC template on patient reach, staff adoption, and fidelity to the intervention protocol.

Main Methods:

  • Retrospective chart review of the Connect-Home study.
  • Analysis of implementation outcomes including patient reach, staff adoption, and fidelity to the TPOC protocol.

Main Results:

  • The TPOC template achieved 100% reach to eligible patients (N=68).
  • High staff adoption was observed, with documentation from four disciplines in 90.6% of records (N=61).
  • Staff fidelity to the intervention protocol was moderately high at 73% concordance.

Conclusions:

  • An electronic medical record (EMR)-based TPOC template shows promise for enhancing SNF staff's ability to prepare older adults for self-care at home.
  • Further research is warranted to assess the TPOC protocol's impact on patient outcomes following SNF to home transitions.