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/clinical/nursing-hub/tools/resources/Individualizing-Care-through-RN-Care-October-2017.pdf

201711311

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Clinical Hub,Nursing Hub,Nursing Practice Tools and Resources,Resources

Individualizing Care Through RN Care

Individualizing Care Through RN Care - Clinical Hub, Nursing Hub, Nursing Practice Tools and Resources, Resources


Key Points:
 RN Care is where you’ll find nursing diagnoses, goals, and interventions to guide nursing
care.
 Within the RN Care activity, there is also a “problem” listed called Patient Preferences for
entry of individualized patient needs, values, or preferences for care such as:
 Pt needs pills crushed in applesauce.
 Pt requests no ice in his water.
 Pt is blind in his right eye – consider this for room assignments and room set-up.
 Pt has hearing impairment-hears better when spoken to from left side.
 Any information added in RN Care can be seen on the Nursing tab of the Care Plan and
viewed by all members of the team.
Individualizing Care through RN Care
How do I add individualized information?
1. Go to the Nursing Tab of Care Plan - Click on Additional Problems from RN Care













2. Select the Patient Preferences point.




3. “Edit goal” to enter a description. You can add to or edit previous
documentation as often as needed.










Last revised October 2017, G.Klinkner, CNS