nursing process/ documentation

NURSING PROCESS/DOCUMENTATION

CHAPTER 6

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).

DIAGNOSIS EXAMPLES

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.

IMPACTS OF EVALUATION

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

WALKING ROUNDS

Members of thecare team walkto each client’sroom anddiscuss progressand care witheach other andwith the 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

INCIDENT REPORT

May also be called a “variance.” Informs administration of incident, allows

risk management personnel to consider ways to prevent future similar occurrences.

Alerts insurance company to potential claim and possible need to investigate.

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