Now it is time to evaluate this approach On the third hospital day the patient

Now it is time to evaluate this approach on the third

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Now it is time to evaluate this approach. On the third hospital day the patient is stronger but now complains of left calf pain when taking steps. You must go back to the assessment step of the nursing process. When you assess the leg, you find that the calf is warm, red, and swollen. You notify the physician, who orders tests that confirm the presence of thrombophlebitis in the saphenous vein of the left leg. The physician orders bedrest for the patient to prevent a pulmonary embolus. Now your nursing diagnosis changes to “Impaired physical mobility, level 4, related to impaired leg circulation as evidenced by redness, pain, and swelling of the left calf.” Your nursing
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interventions change to: Maintaining bedrest Elevating the leg to reduce swelling Maintaining moist heat on the leg as ordered by the physician Assessing for changes in the leg, such as decreased swelling, decreased redness and warmth, and decreased pain Assessing for symptoms of a pulmonary embolus, such as chest pain and dyspnea Administering anticoagulants as ordered by the physician The expected outcome changes to Restored physical mobility when blood clot has resolved. As you go through the evaluation process, you realize that everything has changed and nothing from your original plan applies now. Your nursing day will be filled with similar scenarios when you care for patients. One hallmark of a good nurse is that he or she is ready to make changes and use a fresh approach when necessary. Evidence-Based Practice Making Care Plans More Relevant Clinical Question Could care plans be more relevant to patient care and contribute to collaborative care? Evidence At White Plains Hospital in White Plains, New York, the nursing staff felt that current care plans were designed for nurses only and had way too many nursing diagnoses and patient problems to be effective. After research using surveys and EHR review, they determined that a different approach was needed. They developed care plans that were disease specific and interdisciplinary in nature. They included only the patient problems that were preventing them from moving on to the next level of care. Implications for Nursing Practice After performing this research, these nurses found that this type of care plan improved communication between departments and helped them develop a cohesive and collaborative team. Their research after implementing the evidence-based care plans showed improved efficient quality of patient care. Prior to implementing the change in the design and use of care plans, only 60% of patients had a care plan developed. Afterwards, 95% of patients had care plans because they were useful tools in helping patients improve.
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