Nursing Care Plan in Picis

Now that youre getting comfortable with

charting in Picishere 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)
NICU Care Plan

There are six categories pre-built

into this flowsheet. They were
selected based on important
aspects of care for NICU
patients.
NICU Care Plan

Each section has a set of nursing diagnosis in the top

row, a set of related factors in the second row, a set of
outcome indicators or goals in the third row and an
outcome evaluation tool in the last row.
NICU Care Plan Nursing Dx.

The nursing diagnosis are lists of problems or potential

problems that the NICU patient may have. You can select the
most appropriate nursing diagnosis or problem from this list.
Some patients may have more than one.
NICU Plan of CareRelated
factors

Related
factors are
possible
causes for
the patients
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.
NICU Plan of Care Outcome
evaluation

Upon initiating the nursing diagnosis, select a rating for the

severity of the problem. A patient may start out with the
problems outcome evaluation being a 1 or 2, but eventually
get to a 4 or 5 upon discharge.
NICU Plan of care - review

Once daily, (NICU is schedule for 0300), 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 a week (we have selected

Monday by 2200), the entire plan of
care must be reviewed and updated.
This is done using input from
multidisciplinary rounds, family and
your nursing assessment of the
patient.
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
Common NICU Nursing Dx.

Coming soon: Alterations in newborn

parenting
There are additional Problem/Nursing
Dx in the protocols. These may apply
to your patients special needs.
{ Bereavement, Communication
{ Cardiac, Knowledge
{ GI, Neurological
Parenting

This generic parenting

P/ND may work for your
plan of care until we get the
neonatal parenting P/ND
added
NICU Plan of Care

The care plans that are done look very

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

If you would like more nursing

diagnosis added to better fit our patient
population, please let Stephanie or
Janet know.

Review Test