NURS 208: TOPIC 6 - CARE MAPPING, TEACHING, & DOCUMENTATION

What is the first step in the care mapping or care planning process?

The first step is Assessment.

What should be completed during the assessment phase of care planning?

A physical assessment should be completed.

What tool should be filled out during the assessment step of care mapping?

The Nursing Assessment Tool (NAT) should be filled out.

How should information be recorded when filling out the Nursing Assessment Tool?

It should be descriptive to provide detailed and accurate information.

What is the second step in care mapping or care planning?

Analysis

What should you do during the analysis step of care mapping?

Highlight all abnormal data cues, problems, and any data indicating a patient dysfunction on the Nursing Assessment Tool (NAT).

After highlighting abnormal data cues, what should you determine?

Determine if the highlighted information indicates a problem that can be treated by a nursing intervention.

What does the list of problems identified through analysis become?

It becomes your problem list.

What happens after completing the care map?

After completing the care map, care plans are created from the top two nursing diagnoses.

What form is used to write the complete plan of care?

The care plan form is used to write a complete plan of care.

Where do the nursing diagnoses for the care plan come from?

The nursing diagnoses come from the care map.

What should be filled out at the top of the care plan form?

The top of the care plan form must be filled out as directed.

What information should not be included on the care plan form?

Patient identifiers should not be used.

What are the three components of a care plan?

The three components are Problem, Etiology, and Symptoms.

What does the Problem (P) in a care plan represent?

The Problem pertains to the patient’s current health issue and the needed nursing interventions.

What does the Etiology (E) in a care plan identify?

The Etiology identifies the probable causes of the health problem and the conditions involved in its development.

What do the Symptoms (S) in a care plan indicate?

Also known as the defining characteristics, are the signs and symptoms that show the presence of a particular diagnostic label.

What is the format for writing a Problem-Focused Diagnosis?

(Problem-Focused Diagnosis) related to ______ (Related Factors) as evidenced by ______ (Defining Characteristics).

Example of a Problem-Focused Diagnosis?

Impaired skin integrity related to immobility as evidenced by pressure ulcers on the sacral area.

What is a Risk Diagnosis?

A Risk Diagnosis identifies a potential problem that the patient is vulnerable to developing.

What is the format for writing a Risk Diagnosis?

Risk for ______ as evidenced by ______ (Risk Factors).

Example of a Risk Diagnosis?

Risk for infection as evidenced by surgical incision and decreased immune response.

What is the purpose of Outcome Criteria (OCs)?

Outcome Criteria are used to determine whether the nursing goals have been met.

• BMCT

What tone should Outcome Criteria be written in?

They should be written in a positive tone.

How should Outcome Criteria be written in terms of specificity?

They should be specific and measurable.

When including values or numbers in Outcome Criteria, what should be used?

Ranges should be used for values or numbers.

What should Outcome Criteria serve as in relation to the nursing goal?

They should serve as criteria that prove the nursing goal has been met.

How should Outcome Criteria be structured in terms of evaluation?

They should be written so that they can be answered with “yes” or “no.”

What should Outcome Criteria always include regarding time?

They should include a time frame.

What should be considered when setting Outcome Criteria?

They should be reasonable and achievable.

What is client education?

It is an ongoing, goal-driven, interactive process that provides clients with new information and is a fundamental element of a nurse’s scope of practice.

What are some client education goals?

• health promotion

• restoration of health

• adaptation to permanent illness or injury

What is health promotion?

It is any activity that works to improve a client’s health.

What is restoration of health?

It is any activity that works to improve the health of a client with an illness or injury.

What is adaptation to permanent illness or injury?

It involves assisting a client to adapt their life to accommodate permanent health alterations.

What is an important part of effective patient education involving communication?

Listening to your patients and their families

When should teaching begin in the care process?

At the first patient encounter

What should every interaction with a patient be viewed as?

An opportunity to teach

What should patient education always be centered around?

The patient (person)

What are two key strategies to make teaching more effective?

Engage and motivate the patient

What is one factor that promotes learning by motivating the client through understanding the advantages of the information being taught?

Perceived benefit

What factor that promotes learning helps clients better understand and apply health information to make informed decisions?

Enhanced health literacy

Which factor promotes learning by encouraging the client to take an active role in the education process?

Ongoing client participation

What factor that promotes learning involves creating a supportive environment free of criticism or bias?

Nonjudgmental support

Which environmental factor promotes learning by minimizing distractions?

Quiet, low-stimulus environment

What factor promotes learning by reinforcing information through repeated exposure?

Repetition

What are some factors that can hinder learning?

Fear, anxiety, depression, lack of motivation, environmental distractions, psychomotor deficits, physical discomfort (such as fatigue or pain), and timing.

What is client health literacy?

It is the client’s ability to obtain, read, and understand basic health information.

What is the first step in assessing the learner?

Identifying learning needs.

What does assessing learning readiness help determine?

Whether the learner is physically, emotionally, and cognitively prepared to learn.

Why is it important to assess learning style?

To tailor teaching methods to how the learner best processes information.

What does assessing learning strengths allow the educator to do?

Build on the learner’s abilities to enhance understanding and confidence.

Why should the patient’s motivation be considered during assessment?

Because motivation influences engagement, effort, and the likelihood of successful learning.

What is relevance in client education

It is the client’s understanding of why they should be learning the information being provided to them.

What is motivation in client education?

It is the client’s ability to engage in the learning process by deciding when, where, and how they will learn.

What are the common methods used in client education?

Lecture, discussion, panel discussion, demonstration, discovery, role playing

What are the types of materials used in client education?

Audiovisual materials, printed materials, programmed instruction, web-based instruction and technology

What is feedback in the context of learning?

It is helpful information provided to the learner to aid in improvement.

Why must nurses provide feedback to clients during and after educational sessions?

So that clients know they understand the information appropriately.

What is teach back?

It is conducted by asking the client to repeat or demonstrate educational information back to the nurse to confirm understanding.

What are the key considerations when creating teaching plans for older adults?

Identify learning barriers, allow extra time, plan short teaching sessions, accommodate for sensory deficits, reduce environmental distractions, and relate new information to familiar activities or information.

What are some ways to create an effective learning environment for older adults?

Have the room well lit, consider physical changes such as vision and hearing, use large letters and block-style fonts with simple alignment, employ high contrast colors while avoiding a bright variety of colors on a page, evaluate the reading level of materials, and use repetition.

What are the three domains of learning?

Cognitive, affective, and psychomotor.

What is the cognitive domain of learning?

The thinking domain, involving understanding and comprehending information.

What does the cognitive domain focus on?

Understanding, comprehending, and getting the “what” behind the process.

What is the affective domain of learning?

The feeling domain, involving the learner’s attitudes, values, and emotional responses.

What is the psychomotor domain of learning?

The doing domain, involving the physical or mental activities required to learn skills.

What are some suggested teaching strategies for the cognitive domain?

Lecture, panel, discovery, written materials. Ex: teaching someone how to manage blood pressure.

What are some suggested teaching strategies for the affective domain?

Role modeling, discussion, motivational interviewing.

What are some suggested teaching strategies for the psychomotor domain?

Demonstration/return demonstration, use of models/manikins, supervised practice. Ex: teaching someone how to use an inhaler.

What is the preferred term over "compliance" when discussing patient behavior?

Adherence.

What does adherence refer to in a healthcare context?

The extent to which a person’s behavior corresponds with the agreed-upon recommendations from a healthcare provider, uses a team approach to the treatment plan, reflects the patient’s right to choose, and supports an inclusive and active patient role.

How can adherence be promoted among patients and their families/caregivers?

By providing clear instructions that support patient goals, including patients and caregivers as partners in the process, using interactive teaching strategies, and developing strong interpersonal relationships with the patient and their families.

What is documentation in healthcare?

It is a written or electronic legal record of all pertinent interactions with the patient.

What types of data are included in documentation?

It includes data related to assessing, diagnosing, planning, implementing, and evaluating patient care.

How does documentation facilitate patient care?

It facilitates quality, evidence-based patient care.

What legal or financial purposes does documentation serve?

It serves as a financial and legal record.

How does documentation contribute to research?

It helps in clinical research.

How does documentation support clinical decision-making?

It supports decision analysis.

What are the key characteristics of effective documentation, and what does each one entail?

Effective documentation is consistent with professional and agency standards (follows established guidelines), complete (includes all relevant information), accurate (correct and error-free), concise (clear and to the point), factual (based on observed facts), organized and timely (structured logically and recorded promptly), legally prudent (protects against legal issues), and confidential (maintains client privacy).

What are the key elements of documentation?

Content, Timing, Format, Accountability, Confidentiality

What time should you use to document?

Military

What is the purpose of the Institute for Safe Medication Practices (ISMP)?

The ISMP is devoted to preventing errors that occur within health care facilities.

How does the ISMP help reduce confusion and errors in documentation?

The ISMP compiles a list of abbreviations that are appropriate to use with documentation.

What is an Electronic Health Record (EHR)?

It is a systemic, digitized documentation system designed to improve client care.

What type of information does an EHR provide?

It provides comprehensive records of a person’s health history and serves as a means of communication among all health care providers involved in a client’s care.

What does an EHR account for?

It accounts for every treatment, diagnosis, and provider visit for billing purposes.

Can components of an EHR be used in a court of law?

Yes

What should you never do when accessing electronic documentation?

Never use anyone else’s login information.

What kind of password should you use for electronic documentation?

A strong, unique password that is changed frequently.

What should you do after completing documentation?

Log off when documentation is complete.

What should you do before leaving a computer station?

Always log off before leaving a computer station.

How should you protect patient information on a computer monitor?

Ensure the computer monitor/screen is protected to prevent others from seeing information.

What must you ensure when using an electronic signature?

Make sure your name is correct and that your professional credentials are included.

What is considered confidential information?

All information about patients that is written on paper, spoken aloud, or saved on a computer.

What are examples of confidential patient information?

Name, address, phone number, fax number, social security number, reason the person is sick, treatments the patient receives, and information about past health conditions.

What are examples of potential breaches of patient confidentiality?

Displaying information on a public screen, sending confidential emails via public networks, sharing printers among units with differing functions, discarding patient information in trash cans, holding conversations that can be overheard, faxing confidential information to unauthorized persons, and sending confidential messages that can be overheard on cellphones.

What rights do patients have regarding their health records?

Patients have the right to see and copy their health record, update their health record, get a list of disclosures, request a restriction on certain uses or disclosures, and choose how to receive health information.

Who must give verbal orders?

They must be given directly by the physician or nurse practitioner to a registered professional nurse or registered professional pharmacist.

How should verbal orders be recorded in the patient’s medical record?

They should be recorded with the initials VO.