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Nursing

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Protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of ind, families, communities and populations

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nursing process

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serves as the organizational framework for the practice of nursing.

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nursing process

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systematic method by which nurses plan and provide care for patients

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Nurse process 6 phases

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assessment, diagnosis, outcome identification, planning, implementation and evaluation

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assessment

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the RN collects comprehensive data pertinent to the patient's health or the situation

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diagnosis

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the RN analyzes the assessment data to determine the diagnoses or issues

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outcome identification

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the RN identifies expected outcomes for a plan individualized to the patient or situation

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planning

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the RN develops a plan that prescribes strategies and alternatives to attain expected outcomes

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implementation

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the RN implements the identified plan

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evaluation

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the nurse evaluates the patient's progress toward attainment of outcomes

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assessment

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systemic, dynamic process by which the nurse through interaction with the client analyzes data about the client

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cue

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synonym for subjective and objective data

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subjective data

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verbal sttements provided by the patient

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objective data

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observable and measurable signs

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biographic data

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provide info about the facts or events in a person's life

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database

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a large store or bank of info from which nursing diagnoses can be identified.

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data clustering

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occurs when related cues are grouped together, also assists in identification of nursing diagnosis

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diagnose

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identify the type and cause of a health condition; clinical judgment about the client's response to actual or potential health conditions or needs

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diagnosis

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provides the basis for determination of a plan of care to achieve expected outcomes

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problem

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any health care condition that requires diagnostic, therapeutic or education action

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guidelines to help nurse identify the cues

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1. deviations from population norms. 2. any change in the patient's usual health status. 3. developmental delays. 4. dysfunctional behavior. 5. changes in usual behavior

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NANDA

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North American Nursing Diagnosis Association

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Four Components of Nursing Diagnosis

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1. nursing diagnosis title/label. 2. definition of the title/label. 3. contributing/etiologic/related factors and 4. defining characteristics

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defining characteristics

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clincal cues, signs and symptoms that furnish evidence that the problem exists

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actual nursing diagnosis

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human responses to health condition/life processes that exist in an ind, family, or community; three part statement, words "related to" links the first and second parts of the statement. "manifested by" joins the second and third parts of the diagnostic statement ex. constipation related to insuff fluid intake manifested by abdominal distention, no bowel movement for 5 days and straining at stool

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risk nursing diagnosis

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human responses to health conditions/life processes that may develop in a vulnerable ind, family or community; two part statement connected by words "related to" ex. risk for impaired skin integrity related to mechanical forces

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syndrome nursing diagnosis

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used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances; one part statement ex. rape-trauma syndrome has the etiology provided in the label itself

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wellness nursing diagnosis

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juman responses to levels of wellness in an ind, family or community that have a readiness for enhancement; written as a one part statement. Words "readiness for enhanced" are used ex. readiness for enhanced nutrition

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collaborative problems

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certain physiologic complications that nurses monitor to detect onset or changes in status. ex. potential complication: hypoglycemia

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medical diagnosis

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identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, lab test and procedures; physicians make these diagnoses. ex. congestive heart failure

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goal

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statement about the purpose to which an effort is directed. Exm. the nurse might want to prevent constipation or promote activity

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outcome

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states the behaviors that the patient will be able to perform rather than what the nurse will do.

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measurable verbs

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ex. describe, list, walk, demonstrate and verbalize

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planning

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nursing establishes priorities of care, selects and converts nursing interventions into nursing orders and communicates the plan of care using standardized languages or recognized terminology to document the plan

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nursing interventions

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those activities that should promote the achievement of the desired patient outcome

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physician-prescribed interventions

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those actions ordered by a physician for a nurse or other health care professional to perform

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nurse-prescribed interventions

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any actions that a nurse can legally order or begin independently

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nursing orders should include:

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date, signature of nurse responsible for the care plan; subject action verb; qualifying details

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implementation

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established plan is put into action to promote outcome achievement includes ongoing activities of data collection, prioritization, performance of nursing interventions and documentation

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evaluation

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determination made about the extent to which the established outcomes have been achieved

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standardized language

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structured vocabulary that provides nurses with a common means of communication

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nursing-sensitivities outcomes

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the results of outcomes of nursing interventions. These outcomes or indicators are influenced by nursing and can be used to judge effectiveness of care and determine best practices

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managed care

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a health care system that involves adminstrative control over primary health care services in a medical group practice. Redundant facilities and services are eliminated and costs are reduced. Health education and preventive medicine are emphasized

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case management

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the assignment of a health care provider to oversee the case of an ind patient

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clinical pathways

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multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high risk, high volume, high cost types of cases

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variance

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the unexpected event that occurs during the use of a clinical pathway; can be positive or negative

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Auditors

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persons appointed to examine patients charts and health records to assess quality of care

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Chart

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a legal record used to meet the many demands of the health systems

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Charting

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written informaiton contained in the patient records

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Database

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documentation of care

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Kardex/Rand

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a system used to consolidate patient orers and care needs in a centralized, concise way

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Narrative Charting

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a summary form of charting that should include the basic needs of teh patient, whether someone was contacted, care and treatment provided and the patient's response

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Nurse's Notes

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form used by nurses to record their observations, care given and the patinet's response

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Peer Review

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an appraisal of individual nursing conduct by equals

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Quality assurance/assessment/ improvement

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audit that evaluates care and services provided in health care

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SOAPE

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subjective/objective assessment, plan, evaluation, in this more compact form, the care given or action taken is included in teh plan notations

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5 basic purposes of written pateint records

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written communication, permanent record for accountability, legal record of care, teaching, research and data collection

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Diagnosis-related group

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a system is used by Medicare for reimbursement of patient care services

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Traditional Patient Record

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is divided into specific sections or blocks

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Problem-oriented record

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is based on scientific problem solving system

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What is teh purpose of an incident report

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any event not consistent with the routine operation of a health care unit

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Is the incident report included int he patient's record

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no

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Focus Charting

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objective and subjective assessment data

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Charting by Exception

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provides a more organized flow in the nurse's notes

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What type of charting formate usually requires teh most time to complete

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narrative

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What type of charting format most reflects the nursing process

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focus

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P for PIE

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problem list

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POMR is divided into which four major sections

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database, problem list, plan and progress notes

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The problem-oriented medical record

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uses a patient problem list as index for chart documenting

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4 common issues in malpractice related in inadequate documentation

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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

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Identify how home health care documentation relates to reimbursement

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has different implications than in other areas of nursing

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Advantages of computer documentation

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facilitate delivery of patient care and support the data analysis necessary for strategic planning

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Disadvantages of computer documentation

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security is a big concern

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Identify the primary benefit of documenting with clinical pathway

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allow staff from all disciplines to develop integrated care plans from a projected length of stay for patients of a specific case type

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The essential elements of documentations are

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nursing process, observation sources, where to document

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What are the basic guidelines for charting

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do not erase, apply correction fluid or scratch out errors made while recording, record all facts, do not leave blank spaces in nurse's notes, record all entries legibly and in black ink

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Record ownership

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the orginal health care record or chart is the property of teh institution or physician

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Access (legal)

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patient is usually asked to sign a form grating permission for appropriate people

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Confidentiality

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the patient's Bill of Rights and the law quarantee that the patient's medical information will be kept private

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When an error is made by the nurse in charting

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a line is drawn through the error and initialed and then the nurse continues with the charting

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Confidentiality is most often maintained with use of computer charting through the

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assignment of individual passwords

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The patient can gain access to his or her recordscharts

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by following established procedures of the facility or institution

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Confidentiality of the patient's medical informaiton is guaranteed by the

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law

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OBRA requires

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regulated standards for resident assessmetns, individualized care plans and qualifications for health care providers

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Home Health Documentation

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unique problems because of the need for different health care providers to access the medical record

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Long-term Documentation

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supports a multidisciplinary approach in the assessment and planning process of the patients

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Documentation

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if it wasn't charted it was not done, the chart should be an accurate reflection of the client's association with the health care facility

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Systems of Documentation

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narrative hartin, source-oriented charting, problem-oriented medical record (SOAP, PIE), focus charting, charting by exception, computerized documentation, point of care charting, critical pathways

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