Nursing process, documentation and reporting Flashcards
Five steps of nursing process
Assessment Diagnosis Planning Implementation Evaluation
ADPIE
Assessment
Collection, validation and communication of patient data.
Nursing history
Review patient record
Consult with Other professionals
Initial interview
Diagnosis
Analysis of data to identify patient strengths and health probs that independent nursing intervention can prevent or resolve.
Formulate and validate diagnoses
Prioritized list of nursing diagnosis
Planning (and outcome identification)
- expected patient outcomes to prevent, reduce or resolve problems
- Develop nursing interventions
- Setting goals
- develop care plan
- Communicate plan of nursing care
Identify expected outcomes, develop care plan
Implementation
- Carry out plan
- Continue data Collection and modify the plan of care as needed
- Document care
Evaluate
Measure outcomes
Revise plan if needed
Measure
6 phases of Assessment
1- collecting data
2- identifying cues and making inferences
3- validating (verifying) data
4- clustering related data
5- identifying patterns/ testing first impressions
6- reporting and recording data
Clustering data according to functional health patterns (Gordon)
What are they? (10)
1- health perception, 2- nutrition,
3- elimination, 4- cognitive,
5- sleep, 6- self perception,
7- role/ relationship, 8- sexuality/ reproductive,
9- coping/ stress tolerance, 10- values/ belief
Clustering data according to Human needs (Maslow)
5
1-Physiologic/ survival 2- safety/ security 3- love/ belonging 4- self esteem 5- self actualization (grow, change)
NANDA
Nursing dx system
4 major care plan components
EASE Expected outcomes Actual and at risk problems Specific interventions Evaluate/ progress notes
A difference between RN and Lpn
RN - assessment
LPN- data collection
PES method
Aka PRS method
What do initials stand for?
PES: Problem, Etiology , signs and symptoms
PRS: Problem,Related factors, s/sx
What is an example of a PES method?
Impaired communication related to Language barrier as evidenced by speaking and understanding only Spanish.
5 rights of delegation
Right task Right person Right situation Right communication (specific) Right evaluation (rn evals patient’s response and workers performance)
5 components of outcome statement
1- subject: patient, parent.. 2- verb: action needed to meet outcome 3-condition: under what circumstances? 4- performance criteria: how well? 5- target time
SOAP documentation
S- Subjective- what patient says
O—objective- measurable, observable
A— assessment- statement of the problem. Interpretation or conclusions
P- plan-
Can also use SOAP-IER
What does the IER stand for?
I- interventions
E- evaluation- response to tx
R- revision
PIE documentation
P- problem
I- intervention
E- evaluation
Focus charting
Uses DAR
D- data (eg- pain scale 8)
A- action (eg gave morphine)
R- response (eg pain scale 3)
Kardex
Patient data -
SBAR
Situation
Background
Assessment
Recommendation
Which step in the nsg process does a nurse use when analyzing data to determine strengths?
Diagnosing
Difference between: focused assessment Initial assessment Emergency assess Time lapsed assess
- Focused- gather data about condition already diagnosed
- initial- shortly after admission
- emergency- crisis
- time lapsed- compares current status to baseline data
Nursing process is dynamic, systematic, interpersonal and universally applicable.
What do those words mean in relation to the nursing process?
Dynamic means much interaction and overlapping of the steps.
Systematic -ordered sequence of activities.
Interpersonal -human being at the heart of nursing.
Universally Applicable -it is a framework for all nursing activities
Concept mapping
Instructional strategy that requires a learners to identify, graphically display, And link key concepts.
Which group legitimize the steps of the nursing process in 1973 by developing standards of practice to guide nursing practice?
American nurses Association Congress for nursing practice
A list of nursing activities in the order they would most likely occur during the nursing process:
Establishing the database,
interpreting and analyzing patient data,
establishing priorities,
carrying out the plan of care,
measuring how well the patient has achieved desired outcomes,
modifying the plan of care if indicated
steps of the scientific problem-solving process
Problem identification, data collection, hypothesis formulation, Plan of action, hypothesis testing, interpretation of results, evaluation
Minimum data set
Specifies info that must be collected for every patient
Assessment interview phases: (4)
1- preparatory phase- nurse prepares patient and environment for interview
2- introduction- sets tone
3- working phase- collecting subjective data
4- termination is the conclusion of interview
Gordon’s Functional health patterns model
1-Data is collected regarding the health perception and health management of the patient
2. Perception of the major roles and responsibilities in the patient’s life is explored
3- Elimination, activity, sleep, and sexuality are components of the assessment and data collection
Objective data
Data plan based on facts and observations.
Subjective data
Based on emotions and feelings of the patient
Purposes of nursing diagnosis:
4
1- to identify how individual, family or community responds to actual or potential health and life processes
2- identify factors that cause or contribute to health problems (etiologies)
3-identify resources that can be drawn on to prevent or resolve problems
4-serve as a basis to select nursing interventions to achieve outcomes for which the nurse is accountable
If a nursing diagnosis of “deficient knowledge, what goal must be included?
“Client will acquire knowledge about “
What does a 3 part nursing diagnosis consist of?
Data analysis,
Problem identification,
Formulation of nursing diagnosis
I.e. - “nursing diagnosis” related to “etiology” as evidenced by “defining characteristic”
What are the 4 types of nursing dx?
1- actual
2- wellness or health promotion
3- risk
4- syndrome
Actual nursing dx
Identifies current health problem
-such as inadequate airway clearance
Wellness or health promotion nursing dx
Identifies a patients readiness to transition to a higher wellness level-
- such as readiness for enhanced self care to increase cardiac output
Risk diagnosis
Identifies when a patient could be at risk for additional health problems
- such as infection
Syndrome diagnosis
Determines symptoms based on certain situations
Such as post trauma syndrome or relocation stress syndrome
Uses at least 2 nursing dx.
Nursing history
What questions to ask about chief complaint?
Onset? (When? Gradual or sudden?)
Precipitating factor? (what were you doing?)
Description? (How would you describe it?)
Location?(where is discomfort and does it radiate?)
Duration?
Timing? (Continuous, intermittent?)
Frequency?
Intensity? (0-10)
Associated symptoms?
Factors that relieve or worsen?
Common problems related to assessment
Omitting data,
using inappropriate or in adequate assessment tools,
failure to update the initial assessment
Name 5 types of nursing diagnoses (excelsior study guide)
Actual risk, possible, wellness (readiness for enhanced knowledge) syndrome
Outcomes identification and planning (standard 3 and 4 of ANA standards of nursing practice)
Identify expected outcomes
And develop care plan
Name four different guidelines/ standards to follow when Developing a plan of care
- ANA standards of professional nursing practice
- Academy of medical surgical nurses Scope and standards of medical surgical nursing practice
- QSEN Quality and safety in nursing education pre-licensure competencies
- Clinical guidelines
3 different Oral reporting acronyms
Cuban- Confidential, Uninterrupted, Brief , Accurate, Named
SBAR-Situation, background, assessment (action), recommendation
PACE-patient/problem, assessment/action, continuing/changes, evaluation
Phases of therapeutic Relationship
Pre-interaction,
orientation,
working,
termination
Name 4 nursing diagnoses that address therapeutic communication problems
Readiness for enhanced communication,
impaired verbal communication,
impaired social interaction,
ineffective health maintenance
Name six nursing diagnoses that address stress and anxiety
Anxiety,
ineffective coping,
ineffective denial,
defensive coping,
compromised family coping,
decisional conflict
Name 3 Nursing diagnoses that address teaching and learning
Readiness for enhanced coping,
ineffective health maintenance,
readiness for enhanced health management
List some factors that would be assessed in identifying a therapeutic communication problem
Gender, age, language barriers, developmental delays, CNS injury, loose fitting dentures, cultural/spiritual, noise level, presence of support system
List some factors that would be assessed in use of stress and adaptation problems
Physiological signs (increased heart rate, diaphoresis, dilated pupils, dry mouth)
inability to focus, reporting feelings of anxiety,
decreased attention span,
levels of anxiety (mild- moderate -severe -panic)
List some factors that could be assessed for a need for patient teaching
Motivation, readiness to learn, communication barriers, mental illness, learning disabilities, developmental stage, health literacy reading literacy
Interventions to implement for a diagnosis of a problem with therapeutic communication
Establish trust,
use active listening,
therapeutic communication techniques,
provide alternate methods of communication, quiet private space
Interventions to implement for a diagnosis that has to do with patient teaching
Use age appropriate communication techniques,
structure environment to promote learning,
use tools to support cognitive, psychomotor and affective learning -such as audio visual, demonstration and return demonstration
Interventions to implement for diagnoses that have to do with stress and adaptation
Promote effective stress management
Involve patient in decision making
Encourage patient to express feelings
Use pictures or toys for kids
Name two nursing diagnoses that address health promotion and maintenance
Sedentary lifestyle (related to lack of motivation as evidenced by choosing a daily routine lacking in physical exercise)
Ineffective health maintenance
List 3 nursing diagnoses that would pertain to alterations in vital signs.
Ineffective peripheral tissue perfusion
ineffective breathing pattern (Related to pain as evidenced by shallow respirations)
Ineffective Thermoregulation (related to prolonged exposure to sub freezing temperatures as evidenced by temperature of 94.2°F)
Factors to assess related to infection
Developmental stage, Illness, tobacco use, substance abuse, chronic disease, medications, signs of infection
Lab data
Focused assessment related to skin integrity
Braden scale risk assessment for a pressure ulcer development,
age, physical condition,
hydration and nutrition,
circulation, mobility, hygiene,
wound characteristics,
pressure ulcer staging
Lab data
How to assess readiness to learn for:
—Infection prevention and control
—altered skin integrity
Determine knowledge of infection control measures in the home.
Verify patient’s understanding of wound care, treatment and prevention
Interventions to Implement for wound care
Provide high-protein foods,
wound care as ordered,
applying heat and cold therapy, obtaining wound culture,
performing sterile irrigation
Difference between standing orders and protocols
Standing Order: treatments you can perform before contacting the physician for permission.
Protocol: Standard that includes general and specific principles for managing certain patient conditions.
What should nurse do when patient has Achieved each expected outcome?
Terminated plan of care. Patient has met goals
What is one of the main focuses of the Evaluation phase?
Evaluating the patients goal/outcome achievement
A type of evaluation that focuses on the environment that care is provided
Structure evaluation
Focuses on environment, physical facilities and equipment. Organizational policies and procedures
A type of evaluation of nursing care and patient goals while the patient is receiving care
Concurrent evaluation
What type of charting is the SOAP format?
Problem oriented
What type of documentation method does each healthcare group keep data on at separate forms?
Source oriented
What is a problem with Source oriented charting?
Data is fragmented because each healthcare group uses a separate place to document
What is an advantage to source oriented documentation?
Each discipline can easily find and chart pertinent data
According to the 2005 JCAHO requirements, how long after admission does a nurse have to complete px assessment and have documented history and physical in chart.
24 hours
In a nursing diagnosis, what etiology can be used if there are too many etiologies to list or if too complex to list in brief phrase?
Related to complex factors.
When should verifying data be done in nursing process?
At the end of assessment / interview.
What are 3 phases of diagnostic process?
Data analysis
Identification of clients health problems, health risks and strengths.
Formulation of diagnosis
Best places to assess for skin pallor
Soles of feet
Oral mucous membranes
Conjunctiva of eye
Formula for drip rate
Drops per min
(volume ✖️drip factor)➗time in minutes
