You don't necessarily need to change anything in the Planning Phase. See what the second diagnosis and see it takes priority over the Pain. If pain is controlled at the time you assessed, and it was low, maybe it is not a priority during the implementation phase. Maybe the Ineffective Airway Clearance may be if he also had pneumonia.
If you are assigned pain management, you still have to do the interventions. And doesn't mean that won't assess again... The few quick things you take care of on the grid right after the 20 min checks... you will do those quick things again before you leave the room and reassess pain again. At that time if the pain is higher, you can still evaluate pain.
Here is my opinion... You can still evaluate Acute pain even if the pain level is low. Its how you prove that it is still a priority in rationale that will convince the CE. At the time you assessed the first time, the patient was just medicated with pain medication 45 minutes ago. But as soon as the pain med wears off, the patient will still be in pain. If the patient is still in pain, the patient will not participate in treatment regimen, leading to further demise.
Just trying to clarify your response, Tina. So you're saying if outcome is already met before beginning any interventions, we should consider the secondary diagnosis? We don't need to revise the primary diagnosis? Taking Christina's example of Acute Pain, can't we just reword the outcome to say, " Patient will verbalize having pain of less than 2 after interventions"?
You have to fill out the revised planning phase page if you change anything from the initial Planning Phase. Clarification: All I was trying to say is that if the pain is 2 or less, use your clinical judgment and see if Acute Pain is still indeed your priority for this patient. Maybe you want to evaluate your second diagnosis.
For example, For patient with DVT, you had Acute Pain and another diagnosis of Ineffective Peripheral Vascular Perfusion. BY the time you have already entered the Implementation Phase, the CE has already passed your Planning Phase. If the first diagnosis doesn't apply or is not high on a high priority anymore due to patient's low rating of pain, then do the EVALUATION PHASE on Ineffective Peripheral Vascular Perfusion instead.
So, using your previous example of a patient whose 2 diagnoses are Acute Pain and Ineffective Airway Clearance, if we chose Acute Pain as priority in Planning, but decided to use Ineffective Airway Clearance as priority during Implementation- how/when do we tell this to the CE? Or do we not need to? Do we just switch the order of the diagnoses around in Evaluation phase? Thanks! Mona
Your documentation should make it very clear as to what you are trying to convey. Play it safe and when you write anything on your PCS response form, write it in a way that reader is able to get the entire picture of what you are trying to say. I would write in the margin next to the airway diagnosis "Priority Diagnosis for Evaluation" and evaluate the second diagnosis if the acute pain was not such a priority during your implementation phase.
You are writing two ACTUAL diagnosis on the planning phase to get in the door (enter your implementation phase). These two diagnosis were merely a prediction what you think might be patient problems when you walk in the patient's room. Sometimes predictions are not true. So don't hesitate to use the revised planning phase page if something changes to cover yourself.
For example, if you were only able to do 5 DB&C for respiratory management instead of 10, I would cover myself and re-write only the intervention Encourage DB&C x 5 instead of x 10 if I specified in the planning phase (although EC advisers may say you don't need to do the revised planning phase but different CEs are testing you and all of them have different ways of interpretation).
Anything out of your assignment Kardex changes, play it safe. I would even invoke my CDM and say due to physical/emotional jeopardy, I'm invoking CDM and only instructing patient to do 5 instead of 10 as the patient is clearly very fatigued and activity intolerance and also document this in my narrative notes.