Unitek LVN- Quiz #3 (The Nursing Process & Documentation)

ADPIE

1) Assessment

2) Diagnosis

3) Planning

4) Implementation

5) Evaluation

The Nursing Process​

- A method of planning and providing care ​

-It promotes organization ​

-Each step overlaps with previous and subsequent steps​

-The nursing process serves as the organizational framework for the practice of nursing​

-It is a systematic method by which nurses plan and provide care for patients.​

-It involves identifying patient problems and potential problems​

-After identifying, you plan the care, deliver the care and evaluate the care​

The Nursing process

Assess

-Gather information about the clients condition

-Data communicated verbally or written​

-Objective and Subjective data- Initial assessment with history​

-Ongoing focused assessment to provide structure care and identify new problems​

Diagnose

-Identify the clients problems

Plan and identify Outcomes

-Set goals of care and desired outcomes and identify appropriate nursing actions

Implement

-Perform the nursing actions identified in Planning

Evaluate

-Determine if goals met and outcomes achieved

Subjective Data

-Verbal statements

-Includes clients' feelings, perceptions, and descriptions of health status.

- Clients are the only ones who can describe and verify their own manifestations.

Example: "I have lower back pain"

Objective Data

-Nurses observe and measure objective data (findings) during a physical examination.

-Nurses feel, see, hear, and smell objective data through observation or physical assessment of the client.

-Example: Blood Pressure is 160/90​

Focused Assessment

- Is done when the patient is critically ill, disoriented, change in condition or unable to respond.​

-Stay focused on a specific health problem​

-Example: Migraine, low blood sugar​

-Done to determine progress towards the achievement of desired outcomes​

Sources Of Data

Primary Source​

-The patient and the most accurate reporter​

Secondary sources​

-Used when patient is unable to provide information due to altered mental status or age​

-Family members, significant others, medical records, diagnostic procedures, nursing literatures​

Health team members (Physician, PT, dietician, nurses, RT, PT etc.)​

Assessment : Methods of Data Collection

2 Basic Methods

1) Interview/health history​

2) Physical Exam​

Data Collection -Interview/health history​

-Biographic data​

-Why is patient seeking health care​

-Present illness​

-Past health history​

-Family history​

Physical Exam (Head to Toe)

-Used to provide a systematic approach​

-Helps to gathered objective data and identify problems and a “Nursing Diagnosis”.​

-The information gathered also assists the physician in the medical management of the patient. ​

Data Clustering

-Is done by grouping related cues together from data collected​

-Helps identify Nursing Diagnosis​

-Examples are; thirst, dry skin, dry oral mucous membranes, increased body temperature and decreased urine output---cue cluster for “deficient fluid volume”​​

Examples Of A Nursing Diagnosis

-Constipation related to insufficient fluid intake manifested by increased abdominal pressure, no bowel movement for 5 days and straining with defecation​

-Impaired skin integrity r/t soft tissue injury AMB surgical wound on the RLQ of the abdomen.​

Diagnosis - 4 Types

1) Actual Nursing Diagnosis​

2) Risk Nursing Diagnosis​

3) Syndrome Nursing Diagnosis​

4) Wellness Nursing Diagnosis​

Collaborative Problems​

-These are complications that nurses monitor to detect onset or change of status.​

Medical Diagnosis​

-The identification of a disease or condition through a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures​

-The physicians are licensed to make medical diagnosis​

-Examples of medical diagnosis are congestive heart failure, pneumonia, diabetes mellitus, hepatitis B​

Outcomes or Goals

Goals are focused on the nurse

-what the nurse will do or achieve

-What do we expect to happen?​

Outcomes are focused on the patient

-Patient Centered

Outcomes are used in the nursing process, examples: ​

-Pt will verbalize pain of 2/10​

-Pt will eat 80% of his meals ​

-Temperature to return to normal 98.6F​

-Wound to stop oozing and start healing within 2 weeks​

-No more purulent discharge within 2 weeks​

Outcomes or Goals- How are they formed?

How are outcomes formed​

-From the nursing diagnosis​

-The outcome is usually the reversal of the problem e.g.​

-Problem: impaired skin​

-Outcome: intact skin ​

-The nurse uses the nursing diagnosis to develop expected outcomes​

This outcome must be specific, measurable, accurate, realistic, within a time frame (SMART)​

Planning

Nurse develops a plan of care​

-The “How” of the process​

-How do you resolve the problem ​

At this stage of nursing process, the nurse:​

-Establishes priorities of care or interventions​

-Writes desired patient outcomes​

-Selects and converts nursing interventions into nursing orders ​

-Communicates the plan of care.​

Planning- Priority Setting

-Nursing diagnoses are ranked in order of importance for the patient’s life and health. Maslow’s hierarchy is very useful​

-Physiologic needs (are more vital)come before safety and security.​

Safety and security needs come before love and belonging needs.​

Life-threatening and health-threatening problems are ranked before other types of problems.​

Actual problems may be ranked before risk problems.​

-Priorities change as the patient progresses in the hospitalization; as some problems are resolved, new ones can be addressed.​

Implementations/Interventions

-Nurse implements interventions identified in the plan​

-This is the "DOING" phase​

-You list what you should do (e.g dressing changed, antipyretic given, top blanket removed, tepid washcloth applied under armpit​

-Activities that should promote the achievement of the desired patient outcome​

-May include activities that the nurse selects to resolve a nursing diagnosis, to monitor for the development of a risk problem, or to carry out a physician order​

Implementations/Interventions - Nurse/Physician Prescribed

Nursing judgment must be used when carrying out an order​

Nurse-Prescribed Interventions​

-Actions the nurse can legally order or begin independently​

-Providing a back massage, turning patient every 2 hours, monitoring for complications​

Physician-Prescribed Interventions​

-Actions ordered by a physician for a nurse or other health care provider to perform e.g Medications, wound care, diagnostic tests​

Evaluation

Did the plan work or not? Did you meet your goal or not?​

Nurse evaluates client’s progress​

The nurse should make one of three judgments or decisions​

1) The outcome was achieved​

2) The outcome was not achieved​

3) The outcome was partially achieved​

The plan of care is changed during this phase of the nursing process​

Communicating the Nursing Care or Care Plan and Clinical Pathways

Communicating the Nursing Care or Care Plan​

-Written nursing care plan is the product of the nursing process​

-It is important to have written guidelines to promote the continuity of patient care​

-Formats for the written nursing care plan vary among institutions​

-Nursing care plans may be prepared for each patient, be standardized for a group of patients​

Managed Care​

-A health care system whose aim is to enhance specific clinical and financial outcomes within a specific time frame​

Case Management​

-A certified nursing specialty; refers to the assignment of a health care provider to a patient so that the care of that patient is overseen by one individual​

-Assists the patient and family to receive required services, coordinates these services, and evaluates the adequacy of these services​

Critical Thinking

-Critical thinking is the process of purposeful, self-regulatory judgment.​

Critical​

-Decisive importance with respect to outcome​

Thinking​

-Rational reasoning​

Critical Thinkers think with a purpose​

-They question information, conclusions, and points of view.​

-They are logical and fair in their thinking.​

-Critical thinking is a complex process, and no single simple definition explains all of the aspects of critical thinking.​

-The nurse must be able to not only perform skills but also think about what he or she is doing.​

-Nurses use a knowledge base to make decisions, generate new ideas, and solve problems.​

Steps Of Critical Thinking

Identify​

-Identify the Problem or Question​

-Clearly define the issue or question you are addressing.​

-Ask: What exactly am I trying to solve or understand?​

Gather​

-Gather Information​

-Collect relevant data, facts, and evidence from reliable sources.​

-Ask: What do I know? What do I need to know?​

Analyze and Interpret​

-Analyze and Interpret the Information​

-Examine the information for patterns, assumptions, biases, and logic.​

-Ask: Are there inconsistencies or gaps in the information?​

Evaluate​

-Evaluate the Evidence and Arguments​

-Assess the credibility and relevance of sources and arguments.​

-Ask: Are the conclusions supported by evidence? Are the sources trustworthy?​

More Steps Of Critical Thinking

Consider​

-Consider Alternative Perspectives​

-Think about other viewpoints and counterarguments.​

-Ask: What would someone who disagrees say? Could there be another explanation?​

Draw​

-Draw Conclusions​

-Make a reasoned judgment based on the analysis.​

-Ask: What is the best explanation or solution based on the evidence?​

Communicate or Act on​

-Communicate or Act on the Conclusion​

-Clearly express your findings or take informed action.​

-Ask: How can I best explain or implement this decision?​

Reflect on​

-Reflect on the Outcome​

-Review the process and the outcome to improve future thinking.​

-Ask: Was my reasoning sound? What could I do differently next time?​

Characteristics of Critical Thinkers​

-Reflect or think about what is being learned.​

-Make self-correction.​

-Look for relationships between concepts or ideas.​

-Realize they do not know everything.​

-Involve creative thinking.​

-Analyze or critique behaviors.​

​

Ways to Increase Critical Thinking​

-Verbalize thoughts aloud.​

-Hear others think aloud to help learn how other people reason.​

-Study to gain specific theoretical knowledge; ask other people to evaluate their thinking; and use mistakes to learn.​

-Consider the "Why" behind each Problem, Nursing Diagnosis, Intervention, and Evaluation​

-Collaboration​

Critical Thinking Skills​

Analytical Skills​

-Interpretation – Understanding and explaining the meaning of information.​

-Analysis – Breaking down information into parts to explore relationships and patterns.​

-Synthesis- Combining information from different sources or experiences​

-Evaluation – Assessing the credibility and logical strength of evidence and arguments.​

Cognitive Skills​

-Inference – Drawing logical conclusions from available information.​

-Explanation – Clearly and concisely explaining your reasoning and findings.​

-Problem-solving – Identifying solutions to complex issues.​

-Decision-making – Choosing the best course of action among alternatives.​

More Critical Thinking Skills​

Communication Skills​

-Clarification – Asking questions and seeking details to better understand an issue.​

-Presentation – Expressing ideas logically and persuasively.​

-Active listening – Engaging with and understanding others' viewpoints.​

Reflective Skills​

-Open-mindedness – Willingness to consider new or different ideas.​

-Self-regulation – Monitoring and adjusting your thinking process.​

-Curiosity – Desire to learn more and explore beyond the surface.​

Judgment Skills​

-Bias recognition – Identifying personal or external biases.​

-Relevance identification – Recognizing what information is most important.​

-Fair-mindedness – Evaluating all viewpoints without favoritism.​

-Intuition- The ability to understand or sense something about a patient’s condition without conscious reasoning “Gut Feeling”​

Charting or Documentation​

Chart is a legal record used to meet many demands of healthcare systems ​

It is used for :​

-Accreditation​

-Medical insurance ​

-Legal Systems​

-Charting is the process of adding written information to the chart​

-Charting is also known as recording or documenting​

Charting or Documenting

-Documentation involves recording the interventions carried out to meet patient’s needs​

-A Good documentation reflects nursing process​

-Documentation is an integral part of the implementation phase of the nursing process​

It is important to document:​

-The type of intervention​

-The time care was given​

-Signature of the person providing care​

Purposes of Patient Records​

Five Basic Purposes for Written Record​

1) Written communication​

2) Permanent record for accountability​

3) Legal record of care​

4) Teaching​

5) Research and data collection​

Recorded information is not as easily lost or altered like spoken words​

Purposes of Patient Records

Auditors​

-People appointed to examine patients’ charts and health records to assess quality of care​

Peer Review​

-An appraisal by professional co-workers of equal status​

Quality Assurance/Assessment/Improvement​

-An audit in health care that evaluates services provided and the results achieved compared with accepted standards​

Purposes of Patient Records- Nurse’s Notes​

-The form on the patient's chart on which nurses record their observations, care given, and the patient's responses​

-Reimbursement by insurance companies or government programs (managed care) is only for the documented patient care .​

-The quality and accuracy of the nurse's notes are extremely important.​

-Correct spelling, grammar, and punctuation, as well as good penmanship and other writing skills, are important in documentation.​

-Information recorded in the chart should be clear, concise, complete, and accurate.​

Charting Rules

-All sheets should have the correct patient’s name, date, and time​

-Use only approved abbreviations and medical terms​

-Be timely, specific, accurate, and complete​

-Write legibly​

-Draw a line through errors and initial (When using paper charting)​

-Follow rules of grammar and punctuation​

-Fill all spaces; leave no empty lines ​

-Chart factual information, not opinions​

-Chart after care is given, not before​

-Must document “Late Entry” when note is late​

Documentation NO NO's

Cases of malpractice lawsuits involve one or more common forms of inadequate documentation:​

-Not charting correct time​

-Not recording verbal orders or having them signed by the physician​

-NO Charting in advance to save time​

-Documenting incorrect data or opinions​

Common Medical Abbreviations and Terminology​

H&P​ History & Physical

DNR​- Do No Resuscitate

NPO​- Nothing By Mouth

ADL​- Assisted

AD LIB​ - Up as tolerated or Desired

I&O​ - Intake & Output

BRP​- Bathroom Privileges

PRN​- As needed

STAT​- Immediately

Methods of Recording​

Traditional Chart​

-Chart is divided into specific sections or blocks.​

-Emphasis is placed on specific sheets of information.​

-Typical sections are admission sheet, physician’s orders, progress notes, history and physical examination data, nurse’s admission information, care plan and nurse’s notes, graphics, and laboratory and x-ray reports.​

Problem-Oriented Medical Record​

-This is based on the scientific problem-solving system or method.​

-Principal sections are database, problem list, care plan, and progress notes​

-Database​

-The accumulated data from the history and physical examination, and diagnostic tests are used to identify and prioritize the health problems on the master medical and other problem lists.​

-Problem list​

-Active, inactive, potential, and resolved problems serve as the index for chart documentation.​

-A care plan with nursing diagnosis is developed for each problem by disciplines involved with the patient’s care.​

Methods of Recording- SOAPIER​

S – Subjective information​

O – Objective Information

A – Assessment​

P – Plan​

I – Intervention​

E – Evaluation​

R – Revision​

Methods of Recording- Focused Charting​

-Instead of problem lists, a modified list of nursing diagnoses is used as an index for nursing documentation.​

-This format uses the nursing process and the more positive concept of the patient's needs rather than the medical diagnoses and problems.​

-Focus uses nursing diagnoses not problem list.​

SBAR

S: Situation

B: Background

A: Assessment

R: Recommendation

Basic Guidelines for Documentation- Charting By Exception​

-Complete physical assessments, observations, vital signs, IV site and rate, and other pertinent data are charted at the beginning of each shift.​

-During the shift, only additional treatments given or withheld, changes in patient condition, and new concerns are charted.​

-More detailed flow sheets, which reduce the time needed to chart, are used with this method.​

Other Documentations Forms & Examples

Nursing Care Plan​

-Preprinted guidelines used to care for patients with similar health problems​

-Developed to meet the nursing needs of a patient​

-Based on nursing assessment and nursing diagnosis​

Incident Report​

-Form that is filled out with any event not consistent with the routine care of a patient​

-Used when patient care was not consistent with facility or national standards of expected care​

-Give only objective, observed information​

-Do not admit liability or give unnecessary details​

-Do not mention the incident report in the nurse’s notes​

Documentation and Clinical (Critical) Pathways​

-Managed care is a systematic approach that provides a framework to target the coordination of medical and nursing interventions.​

-Allows staff from all disciplines to develop integrated care plans for a projected length of stay for a specific case type.​

-The nurse and other team members use the pathways to monitor a patient's progress and as a documentation tool.​

Long-Term Health Care Documentation & OBRA​

Omnibus Budget Reconciliation Act (OBRA) of 1987 regulated standards for resident assessment, individualized care plans, and qualifications for health care providers.​

-Department of health for each state governs the frequency of written nursing records of residents in long-term care facilities.​

-Long-term care documentation supports a multidisciplinary approach in the assessment and planning process of the patients​

FACT Charting

F- Factual

A- Accurate

C- Complete

T- Timely