Nursing Concepts Nursing process and Documentation Exam 2

Report

oral, written, or computer generated communication

Record

written or computer based

Chart or client record

a clinical record

Purposes of client records

- Communication

- Diagnostic and therapeutic orders

- Care planning

- Research

- Education

- Reimbursement

- Legal documentation

- Health care analysis

Ethical and legal considerations

- Ensuring the confidentiality of computer records

- Use a personal password for computer files; do not share the password

- Never leave a computer terminal unattended with data available

- Do not leave client information available for others to see

- Shred

- Follow the agency's policy for documenting sensitive material

Characteristics of Effective Documentation

- Follows agency standards

- Complete Accurate

- Concise

- Factual

- Organized & timely

- Legally prudent

- Confidential

Elements of Documentation

- Content

- Timing

- Format

- Accountability

- Confidentiality

Potential Breaches in Patient Confidentiality

- Displaying information on a public screen

- Sending confidential e-mail via public networks

- Sharing printers among units with differing functions

- Discarding copies of patient information in trash cans

- Holding conversations that can be overheard

- Faxing confidential information to unauthorized persons

- Sending confidential messages overheard pager

Receiving Verbal Orders

- Record orders in the medical record

- Read back the order to verify

- Date and note the time orders were issued

- Record verbal order and name of MD followed by nurse's name and initials

Personal Health Records

- Standalone Personal Health Records

- Tethered/Connected Personal Health Record

Health Information Exchange

- Improves quality and safety

- Links physicians, patients, and organizations

- Gets patients involved in their healthcare

- Helps public officials

- Creates feedback in research/practice

- Implements emerging technology

Methods of Documentation

- Source-oriented records

- Problem-oriented medical records

- PIE Charting Focus charting

- Charting by exception

- Case management model

- Computerized documentation/Electronic health records (EHRs)

Documentation systems

- source: oriented medical record

- Problem: oriented medical record

- Database

- Problem list

- Plan of care

- Progress note

PIE Charting

- Problems

- Interventions

- Evaluation

Focus Charting

- data

- action

- response

Charting by Exception

- flow sheets

- standards of care

Case Management Model

- collaborative pathways

- occurrence charting

Documentation nursing activities

- Admission nursing assessment

- Nursing care plans

- Progress notes

- Flow sheets

- Graphic record

- Medication record

- Acuity record Discharge/transfer summary

- Long-term care and home health documentation

Types of flow sheets

- Graphic record

- 24-hour fluid balance record

- Medication administration record (MAR)

- 24-hour patient care record

- Acuity record

Long-Term Care Documentation

- Depends on practice guidelines

- Resident Assessment Instrument

Home Care Documentation

- homebound patient needing skilled nursing care

- Rehab potential is good

- Patient's status has not stabilized

- Patient is dying

- Patient is making progress in the expected outcomes of care

ISBARR

- Identification/Introduction

- Situation Background

- Assessment

- Recommendation

- Read back of orders/response

Hand-off reports

- Basic identifying information

- Current appraisal of health status

- Current orders

- Abnormal occurrences

- Unfilled orders

- Patient/Family questions

- Reports on transfers/discharges

Characteristics of the Nursing Process

- Patient Centered

- Focused

- Cyclic and Dynamic

- Universally Applicable

- Interpersonal and Collaborative

Five Types of Nursing Assessments

- Comprehensive initial

- Focused

- Emergency

- Time-lapsed

- Assessment of communities and special populations

Assessment step 1

Systematic and continuous collection, analysis, validation, and communication of patient data

Assessment step 2

Data reflect how health functioning is enhanced by health promotion or compromised by illness/injury

Assessment step 3

Database enables the nurse to partner with patients to develop a comprehensive and effective care plan

Assessment step 4

Database includes all the pertinent patient information collected by the nurse and other health care processionals

Characteristics of Nursing Assessments

- Purposeful

- Prioritized

- Factual & Accurate

- Systematic

- Relevant

- Recorded in standard manner

- complete

Medical Assessment

target data pointing to pathologic conditions

Nursing Assessment

Focus on the patient's response to a health problem

Assessing

- Preparing for data collection

- Collecting data

- Identifying cues and making inferences

- Validating data

- Clustering related data and identifying patterns

- Reporting and recording data

Establishing Assessment Priorities

- Health Orientation

- Developmental Stage

- Culture

- Need for Nursing

Objective

- Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them.

- Ex: Elevated temperature, skin moisture, vomiting

Subjective

- Information perceived only by the affected person

- Ex: Pain experience, feeling dizzy, feeling anxious

Sources of Data

- Nursing and other health care literature

- Family & significant others

- Patient

- Patient Record

- Consultants

- Other Health Professionals

- Lab Reports/Diagnostic Studies

The Skill of Nursing Observation

- Determines the patient's current responses (physical & emotional)

- Determines the patient's current ability to manage care - Determines the immediate environment and its safety

- Determines the larger environment (hospital or community)

Phases of Nursing Interview

- Preparatory Phase

- Introduction

- Working Phase

- Termination

Components of a Nursing Health History

- Allergies

- Hospitalizations

- Chief Complaint

- Past Medical History

- Biographical Data

- History of Present Illness

- Past Surgical

- History

- Patterns of Health Care

- Review of Systems

- Social History

- Psychological Data

- Medications

- Family History

- Lifestyle

Purpose of a Nursing Physical Assessment

- Appraisal of health status

- Identification of health problems

- Establishment of a database

Problems Related to Data Collection

- Inappropriate organization of the database

- Omission of pertinent data

- Inclusion of irrelevant or duplicate data

- Failure to establish rapport

- Recording an interpretation of data rather than observation

- Failure to update the database.

When to Verify Data

- With a discrepancy between what is being said and what is observed

- When data lacks objectivity

Validating Inferences

- Use proper equipment & procedures for physical exam - Use clarifying statements

- Check findings with research

- Share inferences with other team members

- Compare cues to the knowledge base of normal function

- Check consistency of cues

Privacy, Confidentiality, and Professionalism

1. Always safeguard the privacy of patients

2. Be familiar with the institution's policies on privacy and HIPPA

3. Privacy includes social media mentions- guidelines by ANA

Documentation of Data

- Verbally report critical changes immediately

- Initial database entered on the same day of admission

- summarizes objective & subjective information

- Use good grammar and standard medical abbreviations - Use the patient's own words when possible

- Avoid nonspecific terms subject to individual interpretation

Assessment sets stage for Diagnosis

- Collect data

- Identify cues & make Inferences

- Validate data

- Cluster related data & identify patterns

- Report & record data

- Clinical Reasoning (analyzing, synthesizing, reflecting, making judgments & drawing conclusions

Diagnosing

- Creating a list of suspected problems/diagnoses

- Ruling out similar problems/diagnoses

- Naming actual and potential problems/diagnoses and clarifying what's causing or contributing to them

- Determining risk factors that must be managed

- Identifying resources, strengths, and areas for health promotion

NANDA Nursing Diagnosis

NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION PROVIDES A CLASSIFICATION SYSTEM OR TAXONOMY

DIAGNOSIS

A statement or conclusion regarding the nature of a phenomenon

Diagnostic label

the NANDA diagnosis

Etiology

The risk factor or cause:

Nursing diagnosis

the patients problem statement and the etiology

Predict, prevent, manage, and promote

- Predict the most common and most dangerous complication and take immediate action

- Prevent: if risk factors are present, reduce or control them

- Manage/Promote safety and learning needs

Nursing Diagnosis

Describes patient problems nurses can treat independently

Medical Diagnosis

Describes problems for which the physician direct the primary treatment

Collaborative Problems

Managed by using physician-prescribed and nursing prescribed interventions

Components of a NANDA diagnosis

- Problem (Diagnostic label)

- Etiology (related factors/risk factors)

- Defining characteristics

- Example: Constipation related to long-term laxative use as evidenced by report of no bowel movement in 4 days.

Diagnosis Process

- Analyze Data

- Analyze Health Problems

- Formulate diagnostic statement

Types of Planning

- Initial Planning

- Ongoing Planning

- Discharge Planning

Critical thinking/clinical reasoning in planning

- Keep patient & their preferences central

- Keep 'big picture' in focus

- Trust clinical experience/judgement

- Respect clinical intuitions

- Recognize personal biases

Purpose of desired outcomes & goals

- Provide direction for planning nursing intervention

- Serve as criteria for evaluation

- Enable the patient and the nurse to determine when the problem has been resolved

- Help motivate the patient and the nurse by providing а sense of achievement

Ensuring quality outcomes

- Safe

- Effective

- Patient Centered

- Timely

- Efficient

- Equitable

Common errors in writing outcomes

- Writing outcomes as a nursing intervention

- Using verbs that are not observable and measurable

- Including more than one patient behavior in short-term outcomes

- Writing vague outcomes

Components of a Goals desired outcome statment

- Subject

- Verb

- Conditions

- Criteria of Desired Performance

Nursing Intervention

1. Physician Initiated initiated by the physician in response to a medical diagnosis, but carried out by the nurse

2. Collaborative Interventions treatments initiated by other providers

3. Nursing Interventions Actions nurse takes to help achieve patient goals 이 Monitoring health status & treatment response о Reducing risks о Resolving, preventing, or managing a problem

Writing a nursing intervention

- Use rationalen

- Be specific

- Describe the action

- Give a time element

- Identify who is carrying out the action

Evaluating

To judge or appraise

Process Evaluation

1. Collect & compare data with outcomes

2. Relate nursing activities with outcomes

3. Draw conclusions

4. Review & modify nursing care plan

5 elements of evaluation

- Identify evaluative criteria and standards

- Collect data to determine if criteria and standards are met

- Interpret and summarize findings

- Document judgement

- Terminate, modify, or continue plan