Management of Care / 07

Make sure to:

  • Conduct initial and ongoing assessment of clients’ needs.
  • Complete and regularly update individualized plans of care for all clients.
  • Locate information to provide evidence-based nursing care.

Translating knowledge into practice can be daunting and anxiety-provoking, particularly in a new or unfamiliar work environment. However, registered nurses are expected to safely, effectively, and efficiently manage the care of all of their clients. Generally speaking, case management allows the registered nurse to assess the needs of their clients, plan individualized cost-effective care after determining needs, initiate, evaluate, and update the client’s care plan, plan for discharge, and utilize resources to assist clients in achieving independence (Burke, 2023a).

In this learning experience, concepts from case management are presented to guide learners in determining clients' needs, creating individualized care plans, and using appropriate resources to provide evidence-based nursing care. Learners will receive specific information on how to conduct an assessment, the importance of using assessment data to create, prioritize, and maintain a nursing care plan, as well as how to identify appropriate resources.

In both personal experience and observations of others, it has been noted that the process of comprehending practice-related information and subsequently identifying methods for systematic application leads to enhanced proficiency, increased confidence, and a reduction in anxiety.

1.1 Assessment of Client Needs

According to Burke (2023b) the assessment of clients begins during initial contact with them and continues until they are no longer under the nurse’s care. Reassessments are necessary since a client’s condition can change during their hospitalization, requiring the nurse to adapt their care to meet the client’s evolving needs. 

The initial assessment involves gathering subjective data from the client, their family, or historical data from medical records. This process encompasses collecting identifying information (name, age, address), understanding the primary reason(s) for hospitalization, and eliciting responses to inquiries regarding their medical, surgical, familial, medication, allergy, and psychosocial histories. Furthermore, this assessment mandates a comprehensive review of all body systems.

Table 1 provides an overview of the subjective data highlighting specific information/data that should be obtained in each category.

Table 1

Overview of Assessment Information/Data

Retrieved from Toney-Butler, T. J., & Unison-Pace, W. J. (2022). Nursing Admission Assessment and Examination. http://www.ncbi.nlm.nih.gov/books/nbk493211/

Discharge planning should also begin at this stage. Therefore, assess how the client’s health issues may affect them, as it must be ensuring their return to a safe environment in which they can be as independent as possible. Furthermore, identify individuals and/or organization(s) that can provide social support, taking into consideration their preferences (Kaplan Nursing, 2023).

Following the initial assessment, conduct a head-to-toe examination to obtain objective data, validate data from the review of systems, and identify any issues the client might be unaware of or may have forgotten to mention. Table 2 provides an overview of the systems that should be examined and what should be assessed in each system.

Table 2

Overview of Physical Examination

Retrieved from Toney-Butler, T. J., & Unison-Pace, W. J. (2022). Nursing Admission Assessment and Examination. http://www.ncbi.nlm.nih.gov/books/nbk493211/

The information/data can then be organized, analyzed, and used to create your nursing diagnoses (actual, risk, or wellness) and determine what is needed to meet the client’s needs. Be thoughtful and proactive and consult evidence-based resources to assist you. The healthcare providers on the care team may write orders for diagnostic tests, equipment and/or materials required by the client. For example:

  • A client with a respiratory disorder who has a low oxygen saturation may need oxygen therapy and the necessary supplies.
  • A post-operative client or one on bed rest may need a sequential pressure device.
  • A client with a tracheostomy or one on the ventilator requires suctioning; therefore, a suctioning unit and materials must be readily available.
  • A suctioning machine may also be a regular part of the set up due to the specific setting and the type of clients cared for.
  • Experience in the operating room, peri-anesthesia care, and intensive care unit has involved setups for:
    • Suctioning
    • Various modes of administering oxygen therapy
    •  Pulse oximeter

1.2 Client’s Plan of Care

The client’s plan of care is completed after the initial assessment and whenever there is a change in status and/or reassessment findings. It consists of the expected outcomes or goals related to the client, remains continuous, and includes discharge planning (Burke, 2023b). Completing the plan of care is essential after collaborating with the client and/or their family, as well as other members of the interdisciplinary healthcare team. Considerations include the client’s age, cultural and religious preferences, and their physical, social, and psychological needs.

Prioritize the plan of care using for instance:

  • Airway, breathing and cardiovascular (ABC) status.
  • Maslow’s Hierarchy of Needs (Burke, 2023b).

Incorporate discharge planning information into their plan of care. For example, changes may be necessary in their home, they might require referrals to community services, and education (Kaplan Nursing, 2023). The client may be discharged to their home, hospice, palliative care, or rehabilitation center. This decision is based on factors such as their diagnosis/diagnoses, expected outcome, level of independence, and the need for special healthcare equipment.

According to Toney-Butler and Unison-Pace (2022), discharge planning includes:

  • Determining the client’s transportation.
  • Identifying who will accompany the client. 
  • Addressing potential financial barriers.
  • Providing instructions and medications.
  • Ensuring follow up (referral, information for shelter or hotline).
  • Confirming that both the client and caregiver/guardian understand the instructions and documenting their understanding.

1.3 Client Resources

It is important to research and obtain the resources necessary for clients to facilitate their journey towards their independence. Failure to do so could prevent the achievement of the best possible outcome and result in financial losses for the healthcare organization.

According to Burke (2023a) the resources that clients may need include:

  • Materials
  • Available personnel
  • Financial resources

Upon concluding this learning experience, a greater understanding of case management is acquired. This leads to an enhanced ability to perform initial and ongoing assessment of clients’ needs, create and maintain individualized plan of care for clients, and effectively locate resources for their benefit.

The provided resources further facilitate the expansion of knowledge and the development of proficiency in establishing priorities and applying the content in a case study. The goals include supporting success in the professional workplace.

After reviewing the resources, identify the specific areas in which improvements can be made and concentrate efforts on those areas.

  • Burke, A. (2023a, September 27). Case Management: NCLEX-RN. https://www.registerednursing.org/nclex/case-management/
  • Burke, A. (2023b, September 14). Integrated Processes: NCLEX-RN.  https://www.registerednursing.org/nclex/integrated-processes/#nursing-process
  • Kaplan Nursing. (2023). NCLEX-RN Content Review Guide (9th ed.). Kaplan Test Prep.
  • Toney-Butler, T. J., & Unison-Pace, W. J. (2022, August 29). Nursing Admission Assessment and Examination. http://www.ncbi.nlm.nih.gov/books/nbk493211/

The following links do not belong to Tecmilenio University, when accessing to them, you must accept their terms and conditions.

Readings

Video