nsg 212

What is the nursing process?

A systematic problem-solving process that guides all nursing actions

What is the purpose of the nursing process?

To help the nurse provide goal-directed, client-centered care

What are the two types of goals used in nursing?

Short-term and long-term

What are the steps of the nursing process?

Assess, diagnose, plan, implement, evaluation (ADPIE)

Assessment

Gather data

Diagnosis

Identify client's health needs

Planning Outcomes

Decide goals you want to achieve with your nursing activities

Planning Interventions

choose interventions to help client achieve stated goals

Implementation

action phase when you carry out or delegate actions you previously planned

Evaluation

Judge whether your actions have successfully treated or prevented the client's health problems

Assessment definition

The systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community

What is the difference between a medical diagnosis and a nursing diagnosis?

Medical- focus on disease and pathology

Nursing- focus on the client's response to illness

A professional nurse must perform what portion of the nursing process?

Assessment

While nurse aides, LPNs, and other personnel can collect information such as vital signs, pain reports, and finger-stick glucose levels, It is the responsibility of the professional nurse to...

Assign those tasks, validate the data collected, conduct the interview, and complete the physical assessment

Assessment involves collecting information from...

-the patient

-secondary sources

-interpreting information

-validating the information

Types of data

-subjective: what the patient says

-objective: what can be observed or measured

-primary: obtained directly from the patient

-secondary: obtained through the medical record or another person

Types of assessment

-initial

-ongoing

-comprehensive

-focused

-special needs

Types of special needs assessments

-Nutritional

-Pain

-Cultural

-Spiritual health

-Psychosocial

In which 5 steps of Maslow's hierarchy of needs does nursing live?

-Physiological

-Safety and security

-Love and belonging

-Self-esteem

-Cognitive

Does physiological or psychosocial come first in prioritizing care

Physiological

Levels of problem urgency

-High priority: life threatening

-Medium priority: not a direct threat to life, but may cause destructive physical or emotional changes

-Low priority: Requires minimal supportive nursing intervention

Types of nursing diagnoses

-Actual

-Risk

-Wellness

Nursing-sensitive outcomes

those that can be influenced by nursing interventions

What are the components of a goal statement?

-Subject

-Action

-Performance criteria

-Target time

-Special conditions

Bloom's Domains of Learning

-Psychomotor: involves physical movement

-Cognitive: involves knowledge and intellectual skills

-Affective: involves emotions, feelings, values, and attitudes

What are the 3 types of nursing interventions?

• Independent: Do not require supervision or direction by others; nurse-initiated

-Dependent: Require written orders or supervision of another health professional

-Interdependent: Require nurse to collaborate or consult with another health professional before carrying out the action

What are the 3 outcomes of evaluation of goal?

-Resolved

-In the process of being resolved

-Unresolved

If a goal is unresolved after evaluation, the nurse should...

reassess the diagnosis, interventions, and goals

What is documentation?

anything written or printed on which you rely as record or proof of patient actions and activities

How do you ensure confidentiality of computer records?

-Do not share personal password

-Never leave a computer terminal unattended after logging on

-Do not leave client information displayed on the monitor where others may see it

-Follow agency procedures for documenting sensitive material

-IT personal must install a firewall

Purpose of client records: communication

Prevents fragmentation, repetition, and delays in care

Purpose of client records: planning client care

Nurses use baseline and ongoing data to evaluate the effectiveness of the care plan

Purpose of client records: auditing health agencies

Review client records for quality assurance purposes

Purposes of client records: research

Treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients

Purpose of client records: reimbursement

-From the federal government

-Must contain the correct DRGs (used for determining Medicare coverage)

Purpose of client records: Legal documentation

-Admissible in court as evidence unless client objects because information client gives to primary care provider is confidential

Purpose of client records: health care analysis

Identify agency needs such as over-utilized and underutilized hospital services

When should you chart?

Immediately after care is delivered

4 common issues in malpractice caused by inadequate documentation...

-Not charting the correct time when events occurred

-Failing to record verbal orders or failing to have them signed

-Charting actions in advance to save time

-Documenting incorrect data

What are the two types of documentation?

-Source-oriented record

-Problem-oriented record

Source-Oriented record

-Traditional client record

-Each discipline makes notations in a separate section

-Information about a particular problem is distributed throughout the record

-Narrative charting

Problem-oriented record

-Data arranged according to client problem

-Health team contributes to the problem list, plan of care, and progress notes

-Encourages collaboration

What are the 4 components of a problem-oriented record

-Database: all info known about the client when the client first enters the health care agency

-Problem List: listed in order in which they are identified and others resolved

-Plan of Care: made with reference to active problems, generated by individual who lists the problems

-Progress Notes: made by all health professionals involved in a client's care

Charting by Exception

-Documentation according to standards involves a check mark

-Exceptions to standards described in narrative form on nurses' notes

-Incorporation of flow sheets, standards of nursing care, and bedside chart forms

-Chart ONLY significant findings or exceptions to norms

-Use pre-printed forms and checklists

SOAPIER

subjective, objective, assessment, plan, intervention, evaluation, revision

PIE charting

problem, intervention, evaluation