NURSING PROCESS/ DOCUMENTATION

THE NURSING PROCESS Includes 5 steps: 1.Assessment 2.Diagnosis 3.Planning and outcome identification 4.Implementation 5.Evaluation

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.

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

THE PURPOSE OF ASSESSMENT  To organize a database regarding a client’s physical, psychosocial, and emotional health.  To identify health-promoting behaviors and actual and/or potential health problems.

TYPES OF ASSESSMENT  Comprehensive–provides baseline client data.  Focused–limited to a particular need or health care concern.  Ongoing–includes systematic monitoring of specific problems.

SOURCES OF DATA  Primary source–client or the major provider of information about a client.  Secondary source–sources of data other than client and include family members, other health care providers, and medical records.

TYPES OF DATA  Subjective data–data from client’s point of view, and include perceptions, feelings, and concerns. Collected by interview.  Objective data–observable and measurable, obtained through both physical examination and the results of lab and diagnostic testing.

VALIDATING THE DATA  Prevents misunderstandings, omissions, and incorrect inferences and conclusions.

ORGANIZING THE DATA  Data must be organized.  Data clustering is the process of putting the data together in order to identify areas of the client’s problems and strengths.

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.

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.

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.

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.

TWO-PART NURSING DIAGNOSIS  Part one–problem statement or diagnostic label describing the client’s response to actual or risk health problem or wellness condition.  Part two–etiology or the related cause or contributor to the problem.  Linked by the term related to (r/t).

THREE-PART NURSING DIAGNOSIS  Part one–diagnostic label.  Part two–etiology.  Part three–defining 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).

TYPES OF NURSING DIAGNOSES  Actual nursing diagnosis–indicates that problem exists.  Risk nursing diagnosis–indicates that specific risk factors are present.  Wellness nursing diagnosis–client’s statement of desire to attain a higher level of wellness in some area of function.

PLANNING AND OUTCOME IDENTIFICATION  Third step of the nursing process.  Includes establishing guidelines for the proposed course of nursing action and developing the client’s plan of care.

PLANNING PHASES  Initial planning–developing a preliminary plan of care.  Ongoing planning–updating the client’s plan of care.  Discharge planning–anticipating and planning for the client’s needs after discharge.

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 client’s record.

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.

CATEGORIES OF NURSING INTERVENTIONS  Independent–initiated by the nurse and do not require an order.  Interdependent–implemented in a collaborative manner by nurse in conjunction with other health care professionals.  Dependent–requires an order.

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.

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

ORDERS FOR INTERVENTIONS  Specific order–for individual client.  Standing order–standardized intervention written, approved, and signed by a physician, kept on file to be used in predictable situations.  Protocol–series of standing orders or procedures.

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.

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.

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

PURPOSES OF DOCUMENTATION  Communication  Practice and legal standards  Reimbursement  Education  Research  Nursing audit

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

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

PRACTICE STANDARDS INCLUDE:  State Nursing Practice Acts  Joint Commission on Accreditation of Healthcare Organizations (JCAHO)  Confidentiality  Informed consent  Advance Directives

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.

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 team’s plan of care.

RESEARCH  The client’s 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.

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

PRINCIPLES OF EFFECTIVE DOCUMENTATION 1.Document accurately, completely, and objectively, including any errors. 2.Note date and time. 3.Use appropriate forms. 4.Identify the client. 5.Write in ink. 6.Use standard abbreviations.

PRINCIPLES OF EFFECTIVE DOCUMENTATION (continued) 7.Spell correctly. 8.Write legibly. 9.Correct errors properly. 10.Write on every line. 11.Chart omissions. 12.Sign each entry.

SYSTEMS OF DOCUMENTATION  Narrative charting  Source-oriented charting  Problem-oriented charting  PIE charting  Focus charting  Charting by exception  Computerized documentation  Critical pathways

NARRATIVE CHARTING  Traditional method of nursing documentation.  Chronologic account in paragraphs describing client status, interventions and treatments, and client’s response.  The most flexible system.  Usable in any clinical setting.

SOURCE-ORIENTED CHARTING  Narrative recording by each member of the health care team on separate documents.

PROBLEM-ORIENTED CHARTING  SOAP, SOAPI, AND SOAPIER S: subjective data O: objective data A: assessment data P: plan I: implementation E: evaluation R: revision

PIE CHARTING  P:problem  I:intervention  E:evaluation

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

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.

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.

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.

NURSE’S PROGRESS NOTES  Document client’s condition, problems, complaints, interventions, and client’s response to interventions.  Include MAR, vital signs records, flow sheets, and intake and output forms.

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

DOCUMENTATION TRENDS  Nursing Minimum Data Set (NMDS)  Nursing Diagnoses  Nursing Interventions Classification (NIC)  Nursing Outcomes Classification (NOC)

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 physician’s orders  IV fluid amounts, last PRN medication  Concerns about client

TELEPHONE ORDERS  Date and time  Order as given by the physician  Signature beginning with t.o. (telephone order)  Physician’s name  Nurse’s signature  Physician must countersign