5: Care Planning

This course discusses how assessment data, evidence-based guidelines, professional judgment, and patient values and priorities are merged to create the Care Guide and Action Plan.  

Learning Objectives

1. List two important uses of an up-to-date Care Guide that reflects the goals and intentions of the patient, the caregiver, the physician, and the nurse
2. List the sequence of steps by which a Care Guide is developed and documented
3. Create a Preliminary Care Guide from initial assessment data and document on sample Preliminary Care Guide
4. Identify the three sections of the sample Preliminary Care Guide about which the nurse initiates discussion with the patient’s primary care physician
5. Create an Action Plan

Course summary
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Cecilia M. Daub, MA, BSN, RN, CCM- previously served as a Guided Care Nurse with Kaiser Permanente and as the Clinical Director of Hopkins Elder Plus and as Quality Improvement Coordinator at Johns Hopkins Healthcare. Her geriatric nursing background includes serving as the first clinical nurse for Maryland's Program for All Inclusive Care for the Elderly (PACE) program.  In that role, she also served as a director of a research study comparing satisfaction of nursing assistants in nursing homes versus the PACE program.

Ms. Daub was a facilitator of the curriculum delivery for Guided Care Nursing to the first group of nurses to take the course. Over the years she has found many opportunities to blend her nursing and training expertise.  Ms. Daub is motivated and inspired by a belief that geriatric nursing is a field of practice where a good nurse may make a very significant contribution to patients' lives


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