Week 4 - Health Informatics Lecture Notes

FOV 1992

  • References: 296-512, Tra>Cor(6.1)>Sag(15, 128, 23/180, C 667, OOKES, AF, 280863, Chille, Harmon, 4VAT, STUDY 1, 11.91, 164156, MA 18, Health Informatics, Week 4, RFP, 5cm, R

Learning Outcomes

  • At the end of the lecture and laboratory hours and activities, students will be able to:

    • Utilize evidence-based nursing care using nursing informatics and technology systems.

Informatics Applications in Evidence-based Nursing Practice

A. Computer Generated Nursing Care Plans
B. Critical Pathways
C. Clinical Guidelines
D. E-journals

Computer Information Systems in Nursing

  • Types:

    • Stand-alone

    • Part of a larger system

  • Nursing Information Systems (NIS):

    • Increase efficiency and accuracy in all phases of the nursing process.

    • Help spend more time meeting patient’s needs.

  • Functions:

    • Computer-generated client documentation

    • Electronic medical records (EMR) and Computer-based Patient Records (CPR)

    • Monitoring devices that record vital signs and other measurements into the client record (EMR)

    • Computer-generated nursing care plans and critical pathways.

Action View Setup

  • Sample Patient Data:

    • Patient: AARON, JOHN W (9851), DOB: 04/09/1980, Age: 36y 11m 2w, Weight: 190 lbs on 07/30/15

  • Care Plan Options:

    • Select Careplan, Add to Careplan, View Full List (Dermatology, Orthopedics, etc.)

  • Chief Complaint:

    • Pain Management, Current Back Pain, Other Health Aspects

  • Vital Signs and History:

    • Physical Therapy, Social, Family History, Previous Treatments

Understanding Back Pain

  • Definition:

    • Back pain or low back strain is a response to injury or illness, characterized by pain often due to hurting muscles or ligaments.

  • Causes:

    • Lifting objects, falling, ruptured disk, pinched nerve, infection, osteoporosis, tumors, childbirth.

  • Signs and Symptoms:

    • Sudden or gradual onset, stiffness, trouble bending, pain radiating to legs or buttocks.

  • Types of Pain:

    • Acute pain – lasts less than 3 months. Typically manageable with pain medication.

    • Chronic pain – lasts longer than 3 to 6 months; often complex.

Nursing Care Plans (NCP)

  • Definition:

    • A NCP is a formal process that identifies existing and potential needs/risks, providing communication among nurses and healthcare providers.

  • Process:

    • Begins upon client admission and is updated based on client condition and evaluations.

    • Focuses on individualized care.

Types of Nursing Care Plans

  • Informal vs Formal:

    • Informal: Strategy in the nurse’s mind.

    • Formal: Written/computerized guides.

  • Standardized vs Individualized:

    • Standardized plans for common needs.
      - Individualized plans for unique or unaddressed needs.

Objectives of Nursing Care Plans

  • Promote evidence-based nursing care, holistic care, establish care pathways, identify goals/outcomes, document care, measure nursing care efficiency.

Purposes of Nursing Care Plans

  • Define the nurse’s role, provide individualized care direction, ensure continuity of care, facilitate documentation, and guide staffing assignments and reimbursement.

Assessment and Diagnosis

  • Data Collection via Computer:

    • Admission info, patient health status, history, and chief complaints.

    • Some programs gather additional info through pathways.

  • Nursing Diagnosis:

    • Programs list diagnoses with reference signs/symptoms and generate lists based on specific cases.

Planning and Goal Setting

  • Computer programs may recommend interventions and track outcomes for patient populations. Goals must be measurable and client-center.

    • Short-term Goals: Immediate behavior changes, completed within hours/days.

    • Long-term Goals: Objectives completed over weeks/months, often for home care or chronic conditions.

Implementation

  • Computers record interventions, manage patient transfer/discharge instructions, and automate progress notes, enhancing documentation efficiency.

Evaluation

  • Computers analyze patient data to estimate outcomes, record observations, and reevaluate unmet goals.

Critical / Clinical Pathways

  • Definition:

    • Mapped strategies for patient care, often outlining steps and expected outcomes, initially developed in project planning and adopted by healthcare.

  • Key Steps in Pathway Development:

    • Identify achievable outcomes, patient problem tracking, daily goals, intervention planning.

  • PDCA Framework:

    • Plan Do Check Act principles applied to pathway management.

Integrated Care Pathways (ICPs)

  • Focus on multi-disciplinary, evidence-based, coordinated care patterns for specific patient groups. They provide standardization and document care to improve outcomes.

Benefits of ICPs

  • Enhance patient safety, improve satisfaction, optimize resource use, and provide continuous quality improvement.