Implementing nurse sensitive outcomes into care planning at a long-term care facility

Area of Science:

• Nursing
• Healthcare Informatics
• Long-Term Care

Background:

• Federal regulations mandate uniform assessment tools in long-term care.
• Standardized language is crucial for consistent and effective patient care planning.
• Existing care planning processes may lack uniformity, hindering communication and data analysis.

Purpose of the Study:

• To describe the implementation of standardized nursing language in a long-term care facility's care planning process.
• To integrate Resident Assessment Protocols (RAPs) with standardized nursing terminologies.
• To enhance the care planning process through a structured, database-driven approach.

Main Methods:

• Utilized eighteen Resident Assessment Protocols (RAPs) for data collection.
• Revised computer databases to support standardized care planning.
• Linked North American Nursing Diagnosis Association (NANDA) diagnoses to each RAP.
• Integrated Nursing-Sensitive Outcomes (NOCs) as goals for NANDA diagnoses.
• Connected Nursing Interventions Classifications (NICs) to NANDA diagnoses and NOC outcomes.

Main Results:

• Successfully linked RAPs with NANDA diagnoses, NOC outcomes, and NIC interventions.
• Developed a structured database for standardized care planning.
• Identified frequently used NANDA diagnoses and NOC outcomes within the facility.
• Demonstrated a practical model for implementing standardized nursing language.

Conclusions:

• Standardized language implementation, integrating RAPs, NANDA, NOC, and NIC, enhances long-term care planning.
• This systematic approach improves the consistency and quality of nursing documentation and care.
• The described model provides a framework for other facilities seeking to standardize their care planning processes.