NURSING PROCESS/

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• NURSING PROCESS/
• DOCUMENTATION

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THE NURSING PROCESS

• Includes 5 steps
• Assessment
• Diagnosis
• Planning and outcome identification
• Implementation
• Evaluation

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THE NURSING PROCESS (continued)

• A series of steps that lead to accomplishing some
  goal or purpose.
• A systematic method for providing care to
  clients.
• Provides individualized, holistic, effective and
  efficient client care.
• Clients of all ages and in any care setting.

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ASSESSMENT

• The first step in the nursing process.
• Includes systematic collection, verification,
  organization, interpretation, and documentation
  of data.

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THE PURPOSE OF ASSESSMENT

• To organize a database regarding a clients
  physical, psychosocial, and emotional health.
• To identify health-promoting behaviors and actual
  and/or potential health problems.

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TYPES OF ASSESSMENT

• Comprehensiveprovides baseline client data.
• Focusedlimited to a particular need or health
  care concern.
• Ongoingincludes systematic monitoring of
  specific problems.

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SOURCES OF DATA

• Primary sourceclient or the major provider of
  information about a client.
• Secondary sourcesources of data other than
  client and include family members, other health
  care providers, and medical records.

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TYPES OF DATA

• Subjective datadata from clients point of view,
  and include perceptions, feelings, and concerns.
  Collected by interview.
• Objective dataobservable and measurable,
  obtained through both physical examination and
  the results of lab and diagnostic testing.

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VALIDATING THE DATA

• Prevents misunderstandings, omissions, and
  incorrect inferences and conclusions.

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ORGANIZING THE DATA

• Data must be organized.
• Data clustering is the process of putting the
  data together in order to identify areas of the
  clients problems and strengths.

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INTERPRETING THE DATA

• Organizing data in clusters helps to recognize
  patterns of response or behavior
• Distinguish between relevant, irrelevant.
• Determine whether and where there are gaps in the
  data.
• Identify patterns of cause and effect.

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DOCUMENTING THE DATA

• The nurse must decide which data should be
  immediately reported and which data can just be
  recorded.
• It is essential for accurate and complete
  recording of assessment data to communicate
  information to other health care team members.

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DIAGNOSIS

• Second step in the nursing process.
• Clinical judgment about individual, family, or
  community response to actual or potential health
  problems/life processes.
• Provides the basis for client care through the
  remaining steps.

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MEDICAL DIAGNOSIS

• Clients have both nursing and medical diagnoses.
• A medical diagnosis is a clinical judgment by the
  physician that identifies or determines a
  specific disease, condition, or pathological
  state.

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TWO-PART NURSING DIAGNOSIS

• Part oneproblem statement or diagnostic label
  describing the clients response to actual or
  risk health problem or wellness condition.
• Part twoetiology or the related cause or
  contributor to the problem.
• Linked by the term related to (r/t).

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THREE-PART NURSING DIAGNOSIS

• Part onediagnostic label.
• Part twoetiology.
• Part threedefining characteristics, or signs and
  symptoms, subjective and objective data, or
  clinical manifestations.
• Third part linked to the first two by the term as
  evidenced by (AEB).

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TYPES OF NURSING DIAGNOSES

• Actual nursing diagnosisindicates that problem
  exists.
• Risk nursing diagnosisindicates that specific
  risk factors are present.
• Wellness nursing diagnosisclients statement of
  desire to attain a higher level of wellness in
  some area of function.

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PLANNING AND OUTCOME IDENTIFICATION

• Third step of the nursing process.
• Includes establishing guidelines for the proposed
  course of nursing action and developing the
  clients plan of care.

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PLANNING PHASES

• Initial planningdeveloping a preliminary plan of
  care.
• Ongoing planningupdating the clients plan of
  care.
• Discharge planninganticipating and planning for
  the clients needs after discharge.

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PLANNING INVOLVES

• Prioritizing the nursing diagnoses.
• Identifying and writing client-centered long- and
  short-term goals and outcomes.
• Identifying specific nursing interventions.
• Recording the entire nursing care plan in the
  clients record.

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NURSING INTERVENTIONS

• Actions performed by nurse to help client achieve
  results specified by goals and expected outcomes.
• Refer directly to the related factors or the risk
  factors in nursing diagnoses.
• Are stated in specific terms.
• May change.

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CATEGORIES OF NURSING INTERVENTIONS

• Independentinitiated by the nurse and do not
  require an order.
• Interdependentimplemented in a collaborative
  manner by nurse in conjunction with other health
  care professionals.
• Dependentrequires an order.

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THE NURSING CARE PLAN

• Written guide of strategies to be implemented to
  help client achieve optimal health.
• Begins on the day of admission and continues
  until discharge.

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IMPLEMENTATION

• Fourth step in the nursing process.
• The performance of the nursing interventions
  identified during the planning phase.

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ORDERS FOR INTERVENTIONS

• Specific orderfor individual client.
• Standing orderstandardized intervention written,
  approved, and signed by a physician, kept on file
  to be used in predictable situations.
• Protocolseries of standing orders or procedures.

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EVALUATION

• Fifth step in the nursing process.
• Determines whether client goals have been met,
  partially met, or not met.
• Ongoing evaluation is essential for the nursing
  process to be implemented appropriately.

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THE NURSING PROCESS AND CRITICAL THINKING

• Critical thinkers ask questions, identify
  assumptions, evaluate evidence, examine
  alternatives, and seek to understand various
  points of view.
• Critical thinking can be learned.

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DOCUMENTATION

• Any printed or written record of activities.
• Recording and reporting are the major ways health
  care providers communicate.
• The clients medical record is a legal document
  of all activities regarding client care.

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PURPOSES OF DOCUMENTATION

• Communication
• Practice and legal standards
• Reimbursement
• Education
• Research
• Nursing audit

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COMMUNICATION

• Documentation confirms the care provided to the
  client and clearly outlines all important
  information regarding the client.

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PRACTICE AND LEGAL STANDARDS

• The legal aspects of documentation
• require
• Writing legible and neat
• Spelling and grammar properly used
• Authorized abbreviations used
• Time-sequenced factual and descriptive entries

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PRACTICE STANDARDS INCLUDE

• State Nursing Practice Acts
• Joint Commission on Accreditation of Healthcare
  Organizations (JCAHO)
• Confidentiality
• Informed consent
• Advance Directives

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REIMBURSEMENT

• The federal government requires monitoring and
  evaluation of quality, appropriateness of care
  provided.
• Documentation of intensity of services and
  severity of illness reviewed.
• Failure to document can result in reimbursement
  denied.

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EDUCATION

• Health care students use medical record as tool
  to learn about disease processes, nursing
  diagnoses, complications and interventions.
• Students can enhance critical-thinking skills by
  examining the records and following health care
  teams plan of care.

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RESEARCH

• The clients medical record is used by
  researchers to determine whether a client meets
  the research criteria for a study.
• Documentation can also indicate a need for
  research.

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NURSING AUDIT

• Method of evaluating the quality of care
• Includes
• Safety measures
• Treatment interventions and responses
• Expected outcomes
• Client teaching
• Discharge planning
• Adequate staffing

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PRINCIPLES OF EFFECTIVE DOCUMENTATION

• Document accurately, completely, and objectively,
  including any errors.
• Note date and time.
• Use appropriate forms.
• Identify the client.
• Write in ink.
• Use standard abbreviations.

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PRINCIPLES OF EFFECTIVE DOCUMENTATION (continued)

• Spell correctly.
• Write legibly.
• Correct errors properly.
• Write on every line.
• Chart omissions.
• Sign each entry.

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SYSTEMS OF DOCUMENTATION

• Narrative charting
• Source-oriented charting
• Problem-oriented charting
• PIE charting

• Focus charting
• Charting by exception
• Computerized documentation
• Critical pathways

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NARRATIVE CHARTING

• Traditional method of nursing documentation.
• Chronologic account in paragraphs describing
  client status, interventions and treatments, and
  clients response.
• The most flexible system.
• Usable in any clinical setting.

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SOURCE-ORIENTED CHARTING

• Narrative recording by each member of the health
  care team on separate documents.

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PROBLEM-ORIENTED CHARTING

• SOAP, SOAPI, AND SOAPIER
• S subjective data
• O objective data
• A assessment data
• P plan
• I implementation
• E evaluation
• R revision

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PIE CHARTING

• P problem
• I intervention
• E evaluation

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FOCUS CHARTING

• System using a column format to chart Data,
  Action, and Response (DAR).

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CHARTING BY EXCEPTION

• Only significant findings (exceptions) are
  documented in a narrative form.
• Presumes that unless documented otherwise, all
  standardized protocols have been met and no
  further documentation is needed.

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COMPUTERIZED DOCUMENTATION

• Reduces time taken, increases accuracy.
• Increases legibility.
• Stores, retrieves information quickly.
• Improves communication among health care
  departments.
• Confidentiality and costs can be problems.

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CRITICAL PATHWAY

• Also known as Care Maps.
• Comprehensive pre-printed standard plan
  reflecting ideal course of treatment for
  diagnosis or procedure, especially with
  relatively predictable outcomes.
• Additional forms are needed to complement the
  pathway.

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NURSES PROGRESS NOTES

• Document clients condition, problems,
  complaints, interventions, and clients response
  to interventions.
• Include MAR, vital signs records, flow sheets,
  and intake and output forms.

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DISCHARGE SUMMARY

• Client status on admission and discharge
• Brief summary of the clients care
• Intervention and education outcomes
• Resolved and unresolved problems
• Client instructions about medications, diet,
  food-drug interactions, activity, treatments,
  follow-up, and other needs

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DOCUMENTATION TRENDS

• Nursing Minimum Data Set (NMDS)
• Nursing Diagnoses
• Nursing Interventions Classification (NIC)
• Nursing Outcomes Classification (NOC)

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INFORMATION FOR SHIFT REPORT

• Name, room and bed, age, gender
• Physician, admission date, and diagnosis
• Diagnostic tests or treatments performed in past
  24 hours (results if ready)

• General status, any significant change
• New or changed physicians orders
• IV fluid amounts, last PRN medication
• Concerns about client

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TELEPHONE ORDERS

• Date and time
• Order as given by the physician
• Signature beginning with t.o. (telephone order)
• Physicians name
• Nurses signature
• Physician must countersign