ORGANIZING

PATIENT CARE

PRESENTED BY,
ABITHA PRIYA
NURSING TUTOR
INTRODUCTION:

The overall goal of nursing is to meet the patient nursing

needs with the available resources for providing smooth
day and night 24 hours care to patients and to honor his
rights. To ensure that nursing care is provided to patients,
the work must be organized.
DEFINITION OF PATIENT CARE:
• The services rendered by members of the health profession and non-
professionals under their supervision for the benefit of the patient.

OR

• The prevention, treatment and management of illness and the

preservation of mental and physical well-being through the services
offered by the medical and allied health profession.
PATIENT CLASSIFICATION SYSTEM:
Nurse administrators are facing lot of health care issues in
hospitals, high rocking health care cost, need for decreasing the
length of hospital stay, quality and patient safety and lack of
resources for nursing care. These issues are affecting patients,
families, and nurses also. The management is constantly seeking
reduction of health cost at the same time intends to bring high
quality patient care.
PURPOSE OF PATIENT CLASSIFICATION SYSTEM:
• To provide quality and safe patient care.

• Helps to decide the hours required for each category of patients that
will help to bring best possible patient care outcome as per norms
recommended by the health facility.

• Enhance staff satisfaction through a stress free work environment.

• Monitor changes in patient demographics and care needs.

• Provides information on each patient care unit that directs and
supports staffing decision making.

• Ensure that quality of nursing care is provided in safe environment.

• Assess the level and support services required for each category of
patient.

• Enhance staff satisfaction through stress-free work environment.

 PATIENT CARE CLASSIFICATION
AREA OF CARE CATEGORY 1 CATEGORY 2 CATEGORY 3 CATEGORY 4
EATING FEEDS SELF NEEDS SOME HELP CANNOT FEED SELF CANNOT FEED SELF
IN PREPARING BUT IS ABLE TO AND AMY HAVE
CHEW AND DIFFICULTY IN
SWALLOWING SWALLOWING

GROOMING ALMOST ENTIRELY NEED SOME HELP IN UNABLE TO DO COMPLETELY

SELF SUFFICIENT BATHING, ORAL MUCH FOR SELF DEPENDENT
HYGIENE, ETC.

EXCREATION GET UP AND GO TO NEEDS SOME HELP IN BED, NEEDS BED COMPLETELY
BATHROOM ALONE IN GETTING UP TO PAN/URINAL DEPENDENT
BATHROOM / PLACED.
URINAL
COMFORT SELF SUFFICIENT NEEDS SOME HELP WITH CANNOT TURN COMPLETELY
ADJUSTING POSITION/BED WITHOUT HELP, GET DEPENDENT
DRINK, ADJUST
POSITION, ETC.

TREATMENT SIMPLE ANY TREATMENT MORE ANY TREATMENT ANY ELABORATE

SUPERVISED THAN ONCE PER SHIFT, MORE THAN TWICE /DELICATE
FOLEYS CATHETER CARE, PER SHIFT PROCEDURE
I&O, ETC. REQUIRING TWO
NURSES, VITAL
SIGNS MORE OFTEN
THAN EVERY TWO
HOURS.

HEALTH ROUTINE INITIAL TEACHING OF CARE MORE INTENSIVE TEACHING OF

EDUCATION FOLLOW UP OF OSTOMIES, NEW ITEMS, TEACHING OF RESISTIVE PATIENTS
TEACHING TEACHING DIABETICS, PATIENTS WITH APPREHENSIVE /
MILD ADVERSE REACTIONS MILDLY RESISTIVE
TO THEIR ILLNESS. PATIENTS
 TYPES OF PATIENT CLASSIFICATION SYSTEM
• Three common types are:
1. Descriptive system
2. Check list system
3. Time standard system
DESCRIPTIVE SYSTEM:
This is purely subjective system wherein the nurse selects which category
the patient is best suited.
CHECK LIST SYSTEM:
Another subjective system, wherein the patient is assigned to a numerical
value based on the level of activity in specific categories. The numerical values are
added up to give the nurse an overall rating.
TIME STANDARD SYSTEM:
This is another method where the nurse assigns a time value based on the
various activities needed to be completed for the patients. This time value is sum
up and converted to an acuity level.
Among these three, most commonly used is the descriptive kind of PCS.
These are subdivided into four classifications.
• Self care/minimal care
• Moderate care
• Maximum care
• Intensive care

Self care/minimal care: the first classification of patients who

are recovering and normally requires only diagnostic studies,
minimal therapy, less frequent observations, and daily care for
minor conditions. E.g.: patients waiting for elective surgery.
Moderate care: the patients in this category is moderately ill or under
the recovery stage from a serious illness or operations. They require
nursing supervision or assistance that is related to ambulating and caring
for their own hygiene.

Maximum care: patients needs close attention and complete care all
through the shift. The nurse initiate, supervise and perform most of the
patients activities.
Intensive care: the last category of classification, Wherein the
patients are acutely ill and high level of nurse dependency is
required. Intensive therapy and intensive nursing care is needed
because of the unstable condition of the patients. Frequent
evaluation, observation, monitoring and adjustment of therapy
is also required. A patient in these levels includes those in
critical conditions or in life and death situation.
 DIAGNOSIS RELATED GROUP (DRG) PATIENT
CLASSIFICATION
The DGR system was created in the year 1983. It is a
system which groups and provide care to the patients with
similar diagnosis, and procedure into the same category. The
grouping is based on diagnosis, procedures performed, age, sex,
and status at discharge.
 TYPES OF DGR CLASSIFICATION
• Self care/minimal care: the first classification of patients who
are normal and mostly ambulatory and able to manage their
care means basic care. They are self-dependent and help
themselves without nurse support. These categories of patients
require minimum nursing care hours. They require less
observation and monitoring.
• Moderate care: the patients are moderately ill in this category
and waiting for recovery. These types of patients are guided
and supported by nurses for early ambulation and self care.

• Maximum care: the patients needs maximum nursing care

hours and medical supervision in this group in all shifts. They
need constant monitoring, supervision, and evaluation.
 METHODS OF PATIENT ASSIGNMENT
Assignment is defined as a written document of assignment of
tasks to render patient care for group of patients by trained nursing
personnel working in that ward.

PURPOSE OF ASSIGNMENT
• To assign works to the nursing staff to be done for patient care.

• To ensure the cooperation of the nursing personnel by knowing and

accepting of the work to be done.
 MODES OF ORGANIZING PATIENT CARE OR

METHODS OF PATIENT ASSIGNMENT:

There are several methods of patient care assignments

practiced in hospital. In general, there are two main
classification:
Traditional method

Advanced method
TRADITIONAL METHODS:
• Case method or total patient care
• Functional nursing
• Team nursing
• Modular nursing
• Progressive patient care
• Primary nursing
ADVANCE METHODS:
• Case management
CASE METHOD:
It was the first type of nursing care delivery system. In this method
nurses assumes total responsibility for meeting all the needs of assigned
patients during their time on duty. It involves assignment of one or more
clients to a nurse for specific period of time such as shift. The patient has
a different nurse on each shift and no guarantee of having the same
nurses the next day.
Nurse’s responsibility includes complete care including
treatments, medication administrations and planning of nursing
care.

This model is used in critical care areas, labor and delivery, or

any area where one nurse cares for one patient’s total needs.
MERITS:
• Nurse can attend to total needs of clients due to adequate time
and proximity of interaction.
• Good client nurse interaction and rapport can be developed.
• Client may feel more secure.
• Work load can be equally divided by the staff.
• Nurse’s accountability for their function is built.
• It is used in critical care settings where one nurse provides total
care to a small group of critically ill patients.
DEMERITS:
• Nurse may feel overloaded if most of her assigned patients are sick.

• The greater disadvantage to case nursing occurs, when the nurse is

inadequately trained or prepared to provide total care to the patients.

• The nurse may tend to neglect the needs of patients when the other
patient’s problem or need demands more time.
FUNCTIONAL NURSING:
Emerged in 1930’s in USA during world war 2nd where there is a severe shortage of
nurses in US. It is task focused, not patient-focused. In this model, the tasks are
divided with one nurse assuming responsibility for specific tasks.

For example: one nurse does the hygiene and dressing changes, where another
nurse assumes responsibility for medication administration. Typically a lead nurse
responsible for a specific shift assigns available nursing staff members according to
their qualifications, their particular abilities, and tasks to be completed.
MERITS:
• Each person become very efficient in at specific tasks and a great
amount of work can be done in a short time.

• It is easy to organize the work of the unit and staff.

• Nurse become highly competent with tasks that are repeatedly

assigned to them.

• Less equipment is needed and what is available is usually better cared

for when used only by a few personnel.
DEMERITS:
• Client care may become impersonal, compartmentalized and
fragmented.
• Continuity of care may not be possible.
• Staff become bored and have little motivation to develop self and
others.
• The staff members are accountable for the task.
• Client may feel insecure.
• Only parts of the nursing care plan are known to personnel.
• Patients get confused as so many nurses attend to them, e.g. head
nurse, medicine nurse, dressing nurse, temperature nurse. Etc.
TEAM NURSING:
It is based on the philosophy in which groups of professional and non-
professional personnel work together to identify, plan, implement and
evaluate comprehensive client centered care. The team composed of
registered nurses, licensed nurse practitioners, nurse assistance or
technicians. The team members provide direct patient care to group of
patients, under the direction of the RN team leader in coordinated
effort. The charge nurse delegates authority to a team leader who must
be a professional nurse.
This nurse leads the team usually of 4 to 6 members in the care of
between 15 to 25 patients. The team leader assigns tasks, schedules
care and instructs team members in details of care. A conference is held
at the beginning and end of each shift to allow team members to
exchange information and the team leader to make changes in the
nursing care plan for any patients.
ADVANTAGES:
• High quality comprehensive care can be provided.
• Each member of the team is able to participate in decision making and
problem solving.
• Each member is able to contribute his or her own special expertise or
skills in caring for the patients.
• Improved patient satisfaction.
• Feeling of participation and belonging are facilitated with team
members.
• Work load can be balanced and shared.
• The client is able to identify personnel who are responsible for his care.
DISADVANTAGES:
• Establishing a team concept takes time, effort and constancy of personnel.

• Unstable staffing pattern makes team nursing difficult.

• All personnel must be client centered.

• There is less individual responsibility and independence regarding nursing

functions.

• It is expensive because of the increased number of personnel needed.

• Nurses are not always assigned to the same patients each day, which causes
lack of continuity of care.
MODULAR NURSING:
It’s a modification of team nursing. The concept of modular nursing calls for a
smaller group of staff providing care for a smaller group of patients. The goal is to
increase the RN in planning and coordinating care. The patient unit is divided into
modules or districts, and the same team of care givers is assigned consistently to
the same geographic location. Each location or module has an RN assigned as the
team leader. The team leader is accountable for all patient care and is responsible
for providing leadership for team members and creating a cooperative work
environment.
MERITS:
• Nursing care hours are usually cost effective.

• The client is able to identify personnel who is responsible for his or her care.

• All care is directed by a registered nurse.

• Continuity of care is improved when staff members are consistently assigned to the same
module.

• The RN as team leader is able to be more involved in planning and coordinating care.

• Geographic closeness and more efficient communication save staff time.

• Work load can be balanced and shared.

DEMERITS:
• Cost may be increased to stock each module with the necessary patient care
supplies (medication cart, linens and dressings).

• Establishing team concepts takes time, effort and constancy of personnel.

• Unstable staffing pattern make team difficult.

• There is less individual responsibility and autonomy regarding nursing function.

• All personnel must be client centered.

• The team leader must have complex skills and knowledge.

 PROGRESSIVE PATIENT CARE
Features:
It is a method in which client care areas provide various levels of care.
The central theme is better utilization of facilities, services and
personnel for the better patient care. Here the clients are evaluated with
respect to all level (intensity) of care needed. As they progress towards
increased self care they are marred to units/ wards staffed to best
provide the type of care needed.
PRINCIPAL ELEMENTS OF PPC:
Intensive care or critical care: Patients who require close monitoring
and intensive care round the clock, e.g. patients with acute MI, fatal
dysrhythmias, those who need artificial ventilation, major burns,
premature neonates, immediate post or cardiothoracic, renal
transplant, neurosurgery patients. These units have 9-15 numbers of
beds, life-saving equipment and skilled personnel for assessment,
revival, restoration and maintenance of vital functions of acutely ill
patients. Nursing approach in these units is patient- centered.
Intermediate care: Critically ill patients are shifted to intermediate
care units when their vital signs and general condition stabilizes, e.g.
cardiac care ward, chest ward, renal ward.
Convalescent and Self Care: Although rehabilitation programme
begins from acute care setting, yet patients in these areas participate
actively to achieve complete or partial self-care status. Patients are
taught administration of drugs, life style modification, exercises,
ambulation, self-administration of insulin, etc.
Long-term care: Chronically ill, disabled and helpless patients are
cared for in these units. Nurses and other therapists help the patients
and family members in coping, ambulation, physical therapy,
occupational therapy along with activities of daily living. Patients and
family who need long-term care are, cancer patients, paralyzed and
patients with ostomies.
Home care: Some hospital/centers have home care services. A
hospital based home care package provides staff, equipment and
supplies for care of patient at home, e.g. paralyzed patients, post-
operative, mentally retarded/spastic patient and patient on long
chemotherapy.
Ambulatory care: Ambulatory patients visit hospital for follow up,
diagnostic, curative rehabilitative and preventive services. These areas
are outpatient departments, clinics, diagnostic centers, day care
centers etc.
MERITS:
• Efficient use is made of personnel and equipment.

• Clients are in the best place to receive the care they require.

• Use of nursing skills and expertise are maximized.

• Clients are moved towards self care, independence is fostered where

indicated.

• Efficient use and placement of equipment is possible.

• Personnel have greater probability to function towards their fullest

Demerits:
• There may be discomfort to clients who are moved often.

• Continuity care is difficult.

• Long term nurse/client relationships are difficult to arrange.

• Great emphasis is placed on comprehensive, written care plan.

• There is often times difficulty in meeting administrative need of

the organization, staffing evaluation and accreditation.
PRIMARY CARE NURSING:
It was developed in the 1960s with the aim of placing RNs at the bedside
and improving the professional relationships among staff members. It
supports a philosophy regarding nurse and patient relationship. It is a
system in which one nurse is caring for all the needs of a patient or more
within a 24 hour from admission to discharge. He or she is responsible
for coordinating and implementing all the necessary nursing care that
must be given to the patient during the shift.
If the nurse is not available, the associate nurse responsible for filling in
for the nurse's absence will provide hospital care to the patient based on
the original plan of care made by the nurse. In acute care the primary
care nurse may be responsible for only one patient; in intermediate care
the primary care nurse may be responsible for three or more patients
This type of nursing care can also be used in hospice nursing, or home
care nursing.
Advantages:
• Primary Nursing Care System is good for long-term care, rehabilitation units, nursing clinics,
geriatric, psychiatric, burn care settings where patients and family members can establish
good rapport with the primary nurse.

• Primary nurses are in a position to care for the entire person-physically, emotionally, socially
and spiritually.

• High patient and family satisfaction.

• Promotes RN responsibility, authority, autonomy, accountability and courage.

• Patient-centered care that is comprehensive, individualized, and coordinated; and the

professional satisfaction of the nurse.
Disadvantages:
• More nurses are required for this method of care delivery and it is more
expensive than other methods.
• Level of expertise and commitment may vary from nurse to nurse which may
affect quality of patient care.
• Associate nurse may find it difficult to follow the plans made by another if there is
disagreement or when patient's condition changes.
• It may be cost-effective especially in specialized units such as the ICU.
• May create conflict between primary and associate nurses.
• Stress of round the clock responsibility.
• Difficult hiring all RN staff.
• Confines nurse's talent to his/her own patients.
CASE MANAGEMENT:
• The case manager (RN or social worker with managerial qualification) is assigned
responsibility of following a patient's care and progress from the diagnostic phase
through hospitalization, rehabilitation and back to home care. For eg; case
manager for cardiac surgery patients assists them go through diagnostic
procedures, pre-operative preparations, surgical interventions, family counseling,
post-operative care and rehabilitation.

• Case management involves critical paths, variation analysis; inter shift reports,
case consultation, health care team meetings, and quality assurance.
• Critical paths visualize outcomes within a time frame.

• Variation analysis notes positive or negative changes from the critical

paths, the cause, and the corrective action taken.

• Case consultation may be indicated when the client's condition differs

from the critical path as noted in the inter shift report. Case
consultation is conducted about once a week for a few minutes
immediately after inter shift report to deal with variations.
• Health care team meetings provide an interdisciplinary approach to problem
solving. The case manager needs to identify no more than three priority goals and
decide what team members should be present after considering the patient,
family physician, social service, various therapists, and others involved. The case
manager should set the time and place for the meeting, make the arrangements,
and post the date, time. place, and people to attend.

• The case manager calls the meeting to order, states the goals, initiates discussion,
documents the plans, and sets time limits for follow through. The variance
between what is expected and what happened is assessed for quality
assurance.
Responsibilities of case managers:
• Assessing clients and their homes and communities.

• Coordinating and planning client care.

• Collaborating with other health professionals in the provision of care.

• Monitoring client progress and client outcomes.

• Advocating for clients moving through the services needed.

• Serving as a liaison with third party payers in planning the client 's care.
Merits:
For the patients:
• Case management provides a well-coordinated care experience that can improve
the care outcome, decrease the length of stay, and use multiple disciplines and
services efficiently.

• Provides comprehensive care for those with complex health problems.

• It seeks the active involvement of the patient, family and diverse health care
professionals.

• The hospital length of stay of the patient is reduced.

• Using the minimal resources, maximal health care outcome is achieved.

• This method enhances continuity of patient care through collaborative

practice of diverse health professionals.

• Patients are moved towards self-care, independence is fostered where

indicated.
For the nurse:
• This method facilitates for nurses professional development
and job satisfaction.

• Facilitates the transfer of knowledge of expert clinical staff to

novice staff.
Demerits:
• Nurses identify major obstacles in the implementation of this service, financial barriers
and lack of administrative support.

• Expensive.

• Nurse is client focused and outcome oriented.

• Facilitates and promotes co-ordination of cost effective care.

• Nursing case management is a professionally autonomous role that requires expert

clinical knowledge and decision making skills.

• Continuity of care is difficult as case manger may not always available.

 FACTORS INFLUENCING THE QUALITY PATIENT CARE
• Many variable factors influence the number of nurses needed on a ward in order to
render a high quality of patient care.

• The total number of patient to be nursed.

• The degree of illness of patients (physical dependency).

• Type of service: medical, surgical, maternity, pediatrics and psychiatric.

• The total needs of the patients.

• Methods of nursing care.

• Number of nursing aids and other non professional available, the amount and quality of
• The amount, type and location of equipment and supplies.

• The acuteness of the service and the rate of turnover in patients

according to the degree or period of illness.

• The experience of the nurses who are to give the patient care.

• The number of non-nurses who involve in the patient care, the quality
of their work, their stability in service.

• The physical facilities.

• The number of hours in the working week of nurses and other ward
personnel and the flexibility in hours.

• Methods of performing nursing procedures.

• Affiliation of the hospital with the medical school.

• Methods of assignment-individual, team or functional method.

• The standards of nursing care.

THANKYOU