Fundamentals In Nursing Practice Study Guide PDF

FUNDAMENTALS IN NURSING PRACTICE STUDY GUIDE ON EVIDENCE BASED PRACTICE OBJECTIVE: WHY IS EBP IMPORTANT TO NURSING PRACTICE? o Define evidence-based practice (EBP) o Describe the importance of EBP to nurs...

FUNDAMENTALS IN NURSING PRACTICE STUDY GUIDE ON EVIDENCE BASED PRACTICE OBJECTIVE: WHY IS EBP IMPORTANT TO NURSING PRACTICE? o Define evidence-based practice (EBP) o Describe the importance of EBP to nursing practice It results in better patient outcomes and high-quality patient care It contributes to the science of nursing o Apply the steps of change used in implementing It keeps practice current and relevant evidence-based practice. It increases confidence in decision-making o Describe limitations in relying on research as the Policies and procedures are current and include the primary source of evidence for practice. latest research, thus supporting JCAHO-readiness o Describe research-related roles and responsibilities Integration of EBP into nursing practice is essential for for nurses. high-quality patient care and achievement of ANCC Magnet Recognition Program® (MRP) designation WHAT ARE THE BARRIERS TO IMPLEMENT EVIDENCE- INTRODUCTION BASED PRACTICE During the 1980s, the term “evidence-based medicine” Lack of value for research in practice emerged to describe the approach that used scientific Difficulty in changing practice evidence to determine the best practice. Later, the term Lack of administrative support shifted to become “evidence-based practice” as Lack of knowledgeable mentors clinicians other than physicians recognized the Insufficient time to conduct research importance of scientific evidence in clinical decision- Lack of education about the research process making. Various definitions of evidence-based practice Lack of awareness about research or evidence-based (EBP) have emerged in the literature, but the most practice commonly used definition is, “the conscientious, explicit, Research reports/articles not readily available and judicious use of the current best evidence in making Difficulty accessing research reports and articles decisions about the care of individual patients” (Sackett, No time on the job to read research Rosenberg, Gray, Hayes, & Richardson, 1996). Complexity of research reports Subsequently, experts began to talk about evidence- based healthcare as a process by which research RESEARCH-RELATED ROLES AND RESPONSIBILITIES evidence is used in making decisions about a specific FOR NURSES population or group of patients. Evidence-based practice In today’s EBP environment, all nurses, regardless of and evidence-based healthcare assume that evidence is their educational preparation, need to be able to assume used in the context of a particular patient’s preferences two research-related roles: that of research consumer and desires, the clinical situation, and the expertise of and research team member. the clinician. They also expect that healthcare professionals can read, critique, and synthesize 1. RESEARCH CONSUMER research findings and interpret existing evidence-based Being a research consumer means routinely searching clinical practice guidelines. and reading the current research literature in order to stay current with new insights in client experiences and BRIEF HISTORY: nursing and medical interventions. Florence Nightingale was credited with improving patient care in the 1800s when she noted that Two Skills are Fundamental to this Role: unsanitary conditions and restricted ventilation could adversely affect the health of patients. She went on to A. Locating relevant Literature record medical statistics using patient demographics to ascertain the number of deaths in hospitals and the mortality rate connected to different illnesses and injuries. Archie Cochrane introduced the concept of applying randomized controlled trials (RTC) and other types of research to the nursing practice in 1972. Before Cochrane's contribution to healthcare, medical care centered on unfounded assumptions without consideration for the individual patient. Cochrane proposed that healthcare systems have limited resources so they should only use treatments that are proven to be effective. He believed that RTCs were the most verified form of evidence and his assertion created the foundation for the EBP movement. In 1996 David Sackett introduced the term evidence- based medicine along with a definition that is still widely used today. Unlike Cochrane, Sackett felt that EBP should not only focus on research but should merge evidence, clinical experience and patient values. As other healthcare professions began adopting Sackett's concept for patient care, it was renamed evidenced- based practice. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  B. Critiquing Research Reports 6. RIGHT TO SELF-DETERMINATION The right to self-determination means that participants should feel free from constraints, coercion, or any undue influence to participate in a study. 7. RIGHT TO PRIVACY The anonymity of a study participant must be ensured even if the investigator cannot link a specific person to the information reported. REFERENCES: o Berman, Audre. Kozier & Erb’s fundamentals of nursing: Concepts, practice, and process / Audrey Berman, Shirlee Snyder, and Geralyn Frandsen.—Tenth edition. o Polit, D.F. & Beck, C.T. (2003). Study Guide to Accompany Nursing Research: Principles and Methods. (7th ed.) Philadelphia: Lippincott Williams & Wilkins. 2. RESEARCH TEAM MEMBER This role is particularly important in hospitals that are seeking or wishing to maintain magnet recognition status. Nurses in hospitals with this designation are expected to be involved in research and EBP activities on an ongoing basis. Depending on their individual experience with research, nurses who are working directly with clients can make particularly valuable contributions to research projects, including: – Identifying clinically relevant problems that need to be studied – Reviewing the literature to provide background information for a study – Recruiting study participants – Securing clients’ consent to participate in a study – Designing data collection instruments – Pilot-testing data collection procedures – Collecting research data – Monitoring for adverse effects of study participation – Implementing research interventions – Assisting with interpretation of study findings. 3. PROTECTING THE RIGHTS OF STUDY PARTICIPANTS Because nursing research usually involves humans, a major nursing responsibility is to be aware of and to advocate on behalf of clients’ rights 4. RIGHT TO BE HARMED The risk of harm to a research subject is exposure to the possibility of injury going beyond everyday situations. 5. RIGHT TO FULL DISCLOSURE Even though it may be possible to collect research data about a client as part of everyday care without the client’s particular knowledge or consent, to do so is considered unethical. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTALS IN NURSING PRACTICE DOCUMENTING AND REPORTING COURSE OBJECTIVES: At the end of the session, the students will be able to: List the measures used to maintain confidentiality and security of computerized client records Discuss purposes for client records. Compare and contrast different documentation methods: source-oriented and problem-oriented medical records, PIE charting, focus charting, charting by exception and computerized records. Explain how various forms in the client record (e.g., Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating) Discuss guidelines for effective recording that meet legal and ethical standards. Identify prohibited abbreviations, acronyms, and symbols that cannot be used in any form of clinical documentation. Identify essential guidelines for reporting client data. WHAT IS A RECORD? – Whatever is done but not written, is not considered NOT DONE – Whatever is written, it has been DONE. – Whatever you documented to the chart of the patient, must have been performed and administered. Do not document what has not been done. WHAT IS A RECORD? – A record, also called a chart or client record, is a formal, legal document that provides evidence of a client’s care and can be written or computer based. – The process of making an entry on a client record is called recording, charting, or documenting. ETICAL AND LEGAL CONSIDERATIONS – The American Nurses Association Code of Ethics (2001) states that “... the nurse has a duty to maintain confidentiality of all patient information.” – We should not divulge any patient information to other people. – The client’s record is also protected legally as a private record of the client’s care. – Access to the record is restricted to health professionals involved in giving care to the client. – The institution or agency is the rightful owner of the client’s record. This does not, however, exclude the client’s rights to the same records. – The new HIPAA (Health Insurance Portability and Accountability Act) of 1996 regulations maintain the privacy and confidentiality of protected health information (PHI). HIPAA refers to the Health Insurance Portability and Accountability Act of 1996. – For purposes of education and research, most agencies allow students and graduate health professionals access to client records. LEGAL GUIDELINES FOR DOCUMENTATION GUIDELINES FOR ELECTRIC AND RATIONALE CORRECT ACTION WRITTEN DOCUMENTATION Do not document retaliatory or critical Statements can be used as evidence Enter only objective and factual comments about a patient or care provided for nonprofessional behavior or poor observations of a patient’s behavior or the by another health care professional. Do not quality of care. actions of another health care professional. enter personal opinions. Quote all patients statements. When you document later on, the things that is being verbalized by your patient must be written word by word. Subjective data must be written as verbalized by the patient. Correct all errors promptly. Errors in recording can lead to errors Avoid rushing to complete documentation, in treatment or may imply an attempt be sure that information is accurate and to mislead or hide evidence. complete. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTALS IN NURSING PRACTICE DOCUMENTING AND REPORTING It is very important to countercheck what you have written in your charting especially in your progress notes and in other forms that you have written the documentation. Record all facts. Record must be accurate, factual and Be certain that each entry is factual and objective. thorough. A person reading your documentation needs to be able to determine that a patient received adequate care. Document discussions with providers that If you carry out an order that is written Do not record “physician made error.” you initiate to seek clarification regarding an incorrectly, you are just liable for Instead document that “Dr. Smith was called order that is questioned prosecution as the health care to clarify order for analgesic.” Include the provider. date and time of the phone call, with whom Seek clarification when in doubt. you spoke and the outcome. Document only for yourself. You are accountable for information Never enter documentation for someone that you enter on the patient’s record else (exception: if caregiver has left unit for the day and calls with information that needs to be documented; include date and time of entry and reference specific date and time to which you are referring and name of source of information in entry; include that information was provided via telephone.) Avoid using generalized, empty phrases This type of documentation is Use complete, concise descriptions of such as “status unchanged” or “had good subjective and does not reflect patient assessments and care provided so day.” assessment. documentation is objective and factual. Begin each entry with date and time and Ensures that the correct sequence of Do not wait until the end of shift to record end with your signature and credentials. events is recorded; signature important changes that occurred several documents who is accountable for hours earlier; sign each entry according to care delivered. agency policy. (e.g. F. Marcos, RN) Do not forget to write your name and signature above every time you make documentation. You must sign every entry according to agency policy. Protect the security of your password for Maintains security and confidentiality Once logged into a computer, do not leave computer documentation. of patient medical records. computer screen unattended. Log out when you leave the computer. Make sure that a computer screen is not accessible for public viewing. You must have presence of mind. If you know that you are already finished with documentation be sure to log out before you leave. Do not erase, apply correction fluid or Charting becomes illegible; it appears Draw single line through error , write word scratch out errors made while recording. as if you are attempting to hide error above it and sign your name or initials information or deface a written record. and date it. Then record note correctly. Do not leave blank spaces or lines in a Allows another person to add Chart consecutively, line by line; if space is written nurses’ progress notes. incorrect information in open space. left, draw a line horizontally through it and place your signature and credentials at the end. Chart consecutively, line by line; if space is Illegible entries are easily Never use pencil to document in a written left, draw a line horizontally through it and misinterpreted, causing errors and clinical record. Never erase entries, use place your signature and credentials at the lawsuits; ink from felt-tip pen can correction fluid or use pencil. To indicate an end. smudge or run when wet and may error in written documentation, place a destroy documentation; erasures are single line through the inaccurate not permitted in clinical information and write your signature with documentation. Black ink is more credentials at the end of the text that has legible when records are photocopied been crossed out. or scanned. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTALS IN NURSING PRACTICE DOCUMENTING AND REPORTING – Use authorized abbreviations only GENERAL GUIDELINES FOR RECORDING – Assure patient’s name is on every page of the file – Date and Time –clearly specified – Put a single line through entry errors and affix your – Timing –follows agency protocol but recording is initials (no erasing or “white out”) DONE only AFTER nursing care, not before it Documentation is done just after the nursing COMMONLY USED ABBREVIATIONS care. – Legibility –clear, easy to read ABBREVIATION TERM Right legibly Abd Abdomen – Permanence –if it is to be handwritten, it should be in ABO The main blood group dark ink which is indelible system – Accepted terminology –universally accepted ac Before meals abbreviations and symbols ad lib As desired – Correct spelling –essential for accuracy ADL Activities of Daily Living – Signature –specifies the person who made the entry Adm Admitted or admission and legalizes it. am Morning – Accuracy–“Rights” of documentation; state facts & amb Ambulatory observations, not opinions or interpretations. amt Amount – Sequence –document events in the order which they MEDS Medications occur. mL Milliliter EX: the patient complains of high fever at mod Moderate 10:00 neg Negative DOCU: at 10:00 the patient verbalized that she’s suffering from high fever Ø None – Appropriateness–record only pertinent and # Number of pounds significant information. NPO (NBM) Nothing by mouth – Completeness NS (N/S) Normal Saline – Conciseness –brief but complete 02 Oxygen – Legal prudence –provide proof of the quality of care approx Approximately given to the patient bid Twice daily BM (bm) Bowel Movement BP Blood Pressure IN RECORDING, DO THE FOLLOWING: BRP Bathroom Privileges – Chart all teaching DAT Diet as tolerated Ex: 11:30 AM –taught proper insulin self- Dc Discontinue injection on the abdomen; return Dx Diagnosis demonstration done after teaching h (hr) Hour – Record the client’s actual words by putting quotes I&O Intake and output around the words. (L) Left Ex: patient verbalized: “I do not want to take OD Right eye or Overdose this medication.” OOB Out of bed – Chart the client’s response to interventions. OS Left eye Ex: 8:00 AM -passed 500 ml of straw-colored pˉ After urine after Lasix administration IV pc After meals – Review notes or entry postop Postoperatively preop Preoperatively prn When necessary DOCUMENTATION TIPS: ALWAYS TO Telephone order – Use direct quotations from the patient, family or VO Verbal order visitors WNL Within normal limits – Verify and validate data that has been gathered – Record actions taken – Mention individuals notified about concerns and LEGAL IMPLICATIONS OF ABBREVIATIONS issues – Using unapproved abbreviations put patient’s lives at – Record evaluation of actions risk and the nurse’s license at stake. – Unapproved abbreviations are also a waste of time (trying to figure out what they mean) to the reader. ENSURING SAFETY: LEGAL ASPECTS When there is little space for charting, DO – First, make sure you have the correct chart (MOST NOT abbreviate unnecessarily just to finish IMPORTANT PRIORITY) the work – Write neatly and legibly (with blue or black ink) – Use only the approved and officially recognized – Convey significant details medical and nursing abbreviations – Sign and date every entry – Use proper spelling, grammar and appropriate medical phrases RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTALS IN NURSING PRACTICE DOCUMENTING AND REPORTING IN RECORDING, DO NOT THE FOLLOWING: – Leave blank space for a colleague to chart later. PURPOSES OF CLIENT RECORDS – Chart in advance of the event (e.g. medication or procedure) COMMUNICATION – Use vague terms – The record serves as the vehicle by which different – Chart for someone else health professionals who interact with a client – Use “patient” or “client” as it is in their chart communicate with each other. This prevents – Alter a record even if requested by a superior or fragmentation, repetition, and delays in client care. physician – Record assumptions or words reflecting bias (e.g. PLANNING CLIENT CARE complainer, malingerer, etc..) – Each health professional uses data from the client’s record to plan care for that client. USE OF CHECKLISTS AND FLOWCHARTS AUDITING HEALTH AGENCIES – All forms must be properly filled up – An audit is a review of client records for quality upon admission assurance purposes. during the patient’s course in the ward on discharge RESEARCH The whole duration of the patient in the hospital, you are – The information contained in a record can be a going to document from admission up to discharge of the valuable source of data for research. patient. Page by page, the name of the patient must be written. EDUCATION – Follow agency or institution protocol on the use of the – Students in health disciplines often use client records forms as educational tools. A record can frequently provide a comprehensive view of the client, the illness, CASE: effective treatment strategies, and factors that affect the outcome of the illness. – 2:45 PM: A 76 year old male patient with congestive heart failure was seen at the A&E REIMBURSEMENT with tachycardia and tachypnea upon arrival. – Documentation also helps a facility receive Seen by attending physician, ordered: Lanoxin reimbursement from the federal government. 25 mcg IV STAT then OD, O2 at 3 L/min via face mask and for transfer to high-dependency LEGAL DOCUMENTATION room ASAP as patient getting more anxious – The client’s record is a legal document and is usually with A&E hustle. STAT orders carried out. VS admissible in court as evidence. before transfer: BP=140/87 mmHg; HR=113 beats/min; RR=27/min. HEALTH CARE ANALYSIS – 3:25 PM: Room transfer facilitated. Quick – Information from records may assist health care verbal endorsement was made. Care taken planners to identify agency needs, such as over by ward nurse. Upon review of orders, overutilized and underutilized hospital services. saw STAT medication. Re-checked medication sheet –order unsigned. Checked with A&E nurse but left. Informed charge nurse, decided DOCUMENTATION SYSTEM to give the STAT order as it was unsigned. – 4:30 PM: Vital signs re-checked. BP=100/60 SOURCE-ORIENTED RECORD mmHg; HR=45 beats/min; RR=23 cycles/min. – Narrative chartings a traditional part of the source- The attending physician informed and went to oriented record. It consists of written notes that see patient immediately. Patient transferred to ICU. include routine care, normal findings, and client – Upon review and questioning of the patient’s problems. There is no right or wrong order to the information, although chronologic order is frequently short stay in the ward, the charge nurse informed that STAT Lanoxin was given prior to used. the incident as it was “not given in A&E”. The The nursing process is being used as a framework in doing attending physician refuted that it “was already this, given” by the A&E nurse in his presence. Ward nurse and in-charge asserted that since the order was NOT SIGNED in the medication sheet, they assumed that it was not given. It has been a policy in the hospital that when STAT orders are not given in A&E, they should be given in the ward. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTALS IN NURSING PRACTICE DOCUMENTING AND REPORTING COMPONENTS OF THE SOURCE-ORIENTED RECORD FORM INFORMATION Admission (face) sheet Legal name, birth date, age, gender Social Security number Address Marital status; closest relatives or person to notify in case of emergency Date, time, and admitting diagnosis Food or drug allergies Name of admitting (attending) primary care provider Insurance information Any assigned diagnosis- Initial nursing assessment Findings from the initial nursing history and physical health assessment Graphic record Body temperature, pulse rate, respiratory rate, blood pressure, daily weight, and special measurements such as fluid intake and output and oxygen saturation Daily care Record Activity, diet, bathing, and elimination records Special Flow sheets Examples: fluid balance record, skin assessment Medication Record Name, dosage, route, time, date of regularly administered medications Name or initials of person administering the medication Nurses’ notes Pertinent assessment of client Specific nursing care including teaching and client’s responses Client’s complaints and how client is coping Medical history and physical examination Past and family medical history, present medical problems, differential or current diagnoses, findings of physical examination by the primary care provider Physician’s order form Medical orders for medications, treatments, and so on Physician’s progress notes Medical observations, treatments, client progress, and so on Consultation Records Reports by medical and clinical specialists Diagnostic reports Examples: laboratory reports, x-ray reports, CT scan reports Consultation Reports Physical therapy, respiratory therapy Client discharge plan and referral summary Started on admission and completed on discharge; includes nursing problems, general information, and referral data RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTALS IN NURSING PRACTICE DOCUMENTING AND REPORTING EXAMPLE OF ORGANIZING NARRATIVE CHARTING Based from the data gathered from the patient during the initial interview, you can now formulate a list of nursing problems. SITUATION – Client is postoperative day 2 after abdominal surgery. – Questions to ask yourself: – PLAN OF CARE- The initial list of orders or plan of What assessment data are relevant? care is made with reference to the active problems. What nursing interventions have I Care plans are generated by the individual who lists completed? the problems. What is my evaluation of the result of the interventions and/or Make a care plan for each problem o what is the client’s response to the interventions? – PROGRESS NOTES- A progress note in the POMR is a chart entry made by all health professionals EXAMPLE involved in a client’s care; they all use the same type – 10:00 am Diminished breath sounds in all lung fields of sheet for notes. with crackles in LLL. Not using incentive spirometer (IS). Stated he’s “not sure how to use it.” Temperature 99.6. Instructed how to use IS. Discussed the PROGRESS NOTES importance of deep breathing and coughing after surgery. Administered analgesic for c/o abdominal SOAP pain rating of 5/10. After pain relief (1/10), able to – is an acronym for Subjective data, Objective data, demonstrate correct use of IS. –––––S. Martin, RN Assessment, and Planning. 2:00 pm Using IS each hour. Lungs less diminished S — Subjective data consist of information with fewer LLL crackles. Temp 99. ––––––––––––––– obtained from what the client says. ––S. Martin, RN O — Objective dataconsist of information that is measured or observed by use of the senses (e.g., vital signs, laboratory and x-ray PROBLEM-ORIENTED MEDICAL RECORD results). A — Assessmentis the interpretation or – In the problem-oriented medical record (POMR), or conclusions drawn about the subjective and problem-oriented record (POR), established by objective data. Lawrence Weed in the 1960s, the data are arranged according to the problems the client has rather than P — The planis the plan of care designed to the source of the information. resolve the stated problem. – Example: THE ADVANTAGE OF POMR: S: “I’m worried about the surgery. Last time I had a lot of pain when I go out of bed.” – It encourages collaboration. – The problem list in the front of the chart alerts O: Asking multiple questions about how caregivers to the client’s needs and makes it easier to postoperative pain will be addressed. track the status of each problem. A: Anxiety related to perceived threat of postoperative pain as evidenced by THE DISADVANTAGE OF POMR: statement of prior experience with uncontrolled postoperative pain. – Caregivers differ in their ability to use the required charting format. P: Explain routine post-operative analgesic – It takes constant vigilance to maintain an up-to-date plan of care. Encourage to inform nursing problem list. staff as soon as possible if pain is not – it is somewhat inefficient because assessments and relieved. Explain rationale for early interventions that apply to more than one problem postoperative ambulation. Provide teaching must be repeated. booklet on postoperative nursing care. PIE THE POMR HAS FOR BASIC COMPONENTS – documentation model groups information into three – DATABASE- The database consists of all information categories. PIEis an acronym for Problems, known about the client when the client first enters the Interventions, and Evaluation of nursing care. This health care agency. system consists of a client care assessment flow sheet and progress notes. This are the data gathered during the initial interview with P: Anxiety related to perceived threat of postoperative the patient upon admission. In here, you have the nursing pain as evidenced by statement of prior experience assessment, social and family data results of the physical with uncontrolled postoperative pain. examination and baseline diagnostic tests. I: Explained importance of postoperative ambulation and demonstrated TCDB exercises. Described – PROBLEM LIST- The problem list is derived from the analgesic plan of care. Encouraged to inform nursing database. It is usually kept at the front of the chart staff as soon as possible if pain is not relieved. and serves as an index to the numbered entries in the progress notes. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTALS IN NURSING PRACTICE DOCUMENTING AND REPORTING Provided teaching booklet on postoperative nursing care. E: Stated, “I feel less anxious about postoperative pain now” and performed return demonstration of DOCUMENTATION FORMS TCDB exercises correctly. Needs review of – Admission Nursing Assessment –initial data base; postoperative nursing care. history form – The flow sheet uses specific assessment criteria in a – Nursing care plans particular format, such as human needs or functional – Kardexes health patterns. The time parameters for a flow sheet – Flow sheets can vary from minutes to months – Progress notes – Nursing discharge/referral summaries FOCUS CHARTING – is intended to make the client and client concerns and DOCUMENTING NURSING ACTIVITIES strengths the focus of care. Three columns for recording are usually used: date and time, focus, and ADMISSION NURSING ASSESSMENT/ADMISSION progress notes. The progress notes are organized NURSING HISTORY FORM into (D) data, (A) action, and (R) response, referred – A comprehensive admission assessment, also to as DAR. referred to as an initial database, nursing history, or Data category reflects the assessment nursing assessment, is completed when the client is phase of the nursing process and consists of admitted to the nursing unit. observations of client status and behaviors, including data from flow sheets (e.g., vital NURSING CARE PLANS/STANDARD CARE PLANS signs, pupil reactivity). – The Joint Commission requires that the clinical record Action category reflects planning and include evidence of client assessments, nursing implementation and includes immediate and diagnoses and/or client needs, nursing interventions, future nursing actions. client outcomes, and evidence of a current nursing Response category reflects the evaluation care plan. phase of the nursing process and describes – There are two types of nursing care plans: traditional the client’s response to any nursing and and standardized. medical care. o Traditional – Example: o Standardized D: Patient stated, “I’m worried about the surgery. Last time I had a lot of pain when I KARDEXES go out of bed.” Asking frequent questions – The Kardexis a widely used, concise method of about postoperative pain management. organizing and recording data about a client, making A: Discussed importance of postoperative information quickly accessible to all health ambulation and demonstrated TCDB professionals. The system consists of a series of exercises. Described analgesic plan of care. cards kept in a portable index file or on computer- Described post-operative analgesic plan of generated forms. care that is in place. Provided teaching – The information on Kardexes may be organized into booklet on postoperative nursing care. sections, for example: R: Demonstrated TCDB exercises correctly. Pertinent information about the client, such Needs review of postoperative nursing care. as name, room number, age, admission States, “I feel better knowing how my pain date, primary care provider’s name, will be treated. diagnosis, and type of surgery and date Allergies EXAMPLE OF DAR CHARTING List of medications, with the date of order and the times of administration for each List of intravenous fluids, with dates of Date/hour Focus Progress Notes infusions 2/11/15 Pain D: Guarding List of daily treatments and procedures, such 0900 abdominal as irrigations, dressing changes, postural incision. Facial drainage, or measurement of vital signs grimacing. Rates List of diagnostic procedures ordered, such pain at “8” on as x-ray or laboratory tests scale of 0–10. Specific data on how the client’s physical A: Administered needs are to be met, such as type of diet, morphine sulfate assistance needed with feeding, elimination 4 mg IV. devices, activity, hygienic needs, and safety 0930 R: Rates pain at precautions (e.g., onepersonassist) “1.” States willing A problem list, stated goals, and a list of to ambulate. nursing approaches to meet the goals and relieve the problems. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTALS IN NURSING PRACTICE DOCUMENTING AND REPORTING FLOWSHEETS – Write out units (i.e., 15 units of insulin, not 15 u of – A flow sheet enables nurses to record nursing data insulin). quickly and concisely and provides an easy-to-read – Transcribe the order. record of the client’s condition over time. – Follow agency protocol about the prescriber’s protocol GRAPHIC RECORD - This record typically for signing telephone orders (i.e., within 24 hours). indicates body temperature, pulse, – OTHER: respiratory rate, blood pressure, weight, and, Never follow a voice-mail order. Call the in some agencies, other significant clinical prescriber for a client order. Write it down data such as admission or postoperative and read it back for confirmation. day, bowel movements, appetite, and activity WE MUST REMEMBER: INTAKE AND OUTPUT RECORD - All – Good quality nursing documentation enables routes of fluid intake and all routes of fluid transparent and consistent approaches to the loss or output are measured and recorded planning and delivery of care (Gunningberget on this form. al, 2009) MEDICATION ADMINISTRATION RECORD – It is the cornerstone for professional practice - Medication flow sheets usually include (Leach, 2008) designated areas for the date of the medication order, the expiration date, the REFERENCES: medication name and dose, the frequency of – Kozier, B., et al. (2008). Fundamentals of administration and route, and the nurse’s Nursing: Concepts, Process and Practice (8th signature. Some records also include a place ed.). New Jersey: Pearson Prentice Hall to document the client’s allergies – Joint Commission of Accreditation of Hospital SKIN ASSESSMENT RECORD Organizations. (2004). Unapproved Abbreviations. PROGRESS NOTES – Vincent, C.A., & Coulter A. (2002). Patient – Progress notes made by nurses provide information Safety: What About the Patient? British about the progress a client is making toward – Medical Journal, 02 (11), 76-80 achieving desired outcomes. – Websites: www.jcaho.org NURSING DISCHARGE/REFERRAL SUMMARIES www.qualitysafety.bmj.com – A discharge note and referral summary are www.nrls.npsa.nhs.uk completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. TELEPHONE ORDERS GUIDELINES FOR TELEPHONE AND VERBAL ORDER – Know the state nursing board’s position on who can give and accept verbal and phone orders. – Know the agency’s policy regarding phone orders (e.g., colleague listens on extension and cosigns order sheet). – Ask the prescriber to speak slowly and clearly. – Ask the prescriber to spell out the medication if you are not familiar with it. – Question the drug, dosage, or changes if they seem inappropriate for this client. – Write the order down or enter into a computer on the physician’s order form. – Read the order back to the prescriber. Use words instead of abbreviations (i.e., “three times a day” instead of “tid”). – Have the prescriber verbally acknowledge the read- back (i.e., “Yes, that is correct”) – Record date and time and indicate it was a telephone order (TO). Sign name and credentials. – When writing a dosage always put a number before a decimal (i.e., 0.3 mL) but never after a decimal (i.e., 6 mg). RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan 3. Implementing nursing interventions – For example, whenever possible, the nurse honors the – It is important to explain to the client what client’s expressed preference that interventions be interventions will be done, what sensations to planned for times that fit with the client’s usual schedule expect, what the client is expected to do and what of visitors, works, sleep or eating. the expected outcome. Respect 4. Supervising delegated care – Respect the dignity of the client and enhance self- – If care has been delegated to other health care esteem personnel, the nurse responsible for the client’s – Providing privacy and encouraging clients to make their overall care must ensure that the activities have own decisions are ways of respecting dignity and been implemented according to the care plan. enhancing self-esteem. 5. Documenting nursing activities Encourage – After carrying out the nursing activities, the nurse – Encourage active client participation completes the implementing phase by recording – Active participation enhances the clients sense of the interventions and client responses in the independence and control. nursing progress notes. Supervising Delegated Care 6. Reassessing the client – Nurse still responsible for client’s overall care – Reassess to make sure the intervention is still – Must validate and respond to any adverse findings or needed client response – Client’s condition may have changed Documenting Nursing Activities DETERMINING THE NURSE’S NEED FOR ASSISTANCE – Record nursing interventions and client responses Inability to implement the activity safely – Do not record in advance! Assistance will reduce stress on the client Nurse lacks knowledge or nursing skills to implement a EVALUATING particular nursing activity Judge and appraisal IMPLEMENTING NURSING INTERVENTIONS – This is the 5th phase of nursing process Base Planned, ongoing, purposeful activity – Base actions on scientific knowledge – Which clients and health care professions to – Nursing research and professional standards of care determine the clients progress effectiveness care (evidence-based- practice) when these exist. The nurse plan. must be aware of the scientific rationale as well as possible side effects or complications of all Determines client’s progress, effectiveness of care interventions. plan Continuous process Understand Demonstrates nursing responsibility and – Clearly understand interventions accountability for their actions – Implemented and questions any that are not understood. Evaluating – The final phase of the nursing process, in – The nurse is responsible for intelligent implementation which the nurse determines the client’s progress toward of medical and nursing plans of care. This requires goal achievement and the effectiveness of the nursing knowledge of each intervention, it’s purpose on the care plan. The plan may be continued, modified, or client’s plan of care. terminated. Adapt – Adapt activities to individual client – The client’s belief, values, age, health status and environment are factors that can affect the success of a nursing action. Implement – Implement safe care – Example: when changing a sterile dressing, the nurse practices sterile technique to prevent infection; when giving a medication, the nurse administers the correct dosage by the ordered route. Provide – Provide teaching, support, and comfort – The nurse should always explain the purpose of interventions, what will the client will experience and RELATIONSHIP OF EVALUATING TO OTHER NURSING how the client can participate. PROCESS PHASES – The client must have sufficient knowledge to agree to the plan of care and to be able to assume responsibility Depends on effectiveness of preceding steps for as much as desirable. Assessment data must be accurate and complete Be – So, the nurse can fomulate appropriate nursing – Be holistic diagnoses and desired outcome. – The nurse must always view the client as a whole and consider the client’s responses in that context. Desired outcome must be stated concretelt in behavioral terms to be useful for evaluating RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  Without impreentation/intervetions, there would be – Investigate whether best nursing interventions nothing to evaluate were selected Evaluating and assessing overlap Implementing Upon assessment of respiratory excursion, Nurse Medina – After modifications, begin nursing process detects failure of the client to achieve maximum ventilation. again She and Amanda reevaluate the care plan and modify it to increase coughing and deep-breathing exercises to q2h. REFERENCES: o Carpenito-Moyet, L. J. (2009). Nursing care plans & documentation: nursing diagnoses and collaborative problems. Lippincott Williams & Wilkins. o Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences. o NANDA International, Inc. Nursing Diagnoses: Definitions and Classification 2018–2020, 11th o Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru. © 2017 NANDA International, Inc. Published 20 o Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb's fundamentals of nursing: Concepts, process, and practice. COMPONENTS OF THE EVALUATION PROCESS Singapore: Pearson Education South Asia Pte. COLLECT – Collect data related to the desired outcomes (NOC indicators) COMPARE – Compare the data with outcomes RELATE – Relate nursing activities to outcomes DRAW – Draw conclusions about problem status – The nurse uses the judgements about goal achievement to determine whether the care plan was effective in resolving, reducing, or preventing client problems. CONTINUE, MODIFY, OR TERMINATE – Continue, modify, or terminate the nursing care plan – After drawing conclusions about the status of the client’s problems, the nurse modifies the care plan as indicated. Whether or not goals were not met, a number of decisions need to be made about continuing, modifying, or terminating nursing care. CONTINUING, MODIFYING OR TERMINATING THE CARE PLAN – Critique each phase of the nursing process Assessment – Incomplete or inaccurate databases influence all subsequent steps. Diagnosis – If incomplete – add new diagnosis statements – If complete – analyze whether nursing diagnoses relevant Planning – If inaccurate – goals/outcomes need revision – If accurate – goals/outcomes realistic and obtainable – Have priorities changed? Does client still agree with priorities? o Relate to goal achievement RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  FUNDAMENTALS IN NURSING PRACTICE COLLABORATION & PARTNERSHIP COLLABORATION & PARTNERSHIP CONCEPT & PRINCIPLES OF PARTNERSHIP, COLLABORTATION AND TEAMWORK PARTNERSHIP – State of being a partner and an association of two or more people – It is like a partnership between nurses & doctor PHYSICIAN (witnessed in the clinical area) ¾ Responsible for the medical diagnosis and for – It is the nurse’s responsibility to be prepared to determining the therapy required by a person who is ill partner with client, family, & community. or injured ¾ Doctors: Responsible for providing medical diagnosis COLLABORATION NURSE – A collegial working relationship with another healthcare provider in the promotion of healthcare ¾ Comprised of personnel who provide nursing service to a patient or his family. TEAMWORK ¾ In direct contact with the patient or family members DIETITIAN – The ability to function effectively within the nursing and interpersonal team, fostering open communication, ¾ Supervise the preparation of meals according to the mutual respect, and shared decision-making doctor’s prescription. PHYSIOTHERAPIST TYPES OF HEALTH CARE GROUPS ¾ Functions include assessing mobility and strength, providing therapeutic measures and teaching patients SELF-AWARENESS new skills and measures. – Relationship between one’s perception of oneself ¾ Also known as physical therapist and others perception OCCUPATIONAL THERAPIST – Purpose: Develop or use interpersonal strengths ¾ Assists patients with some impairment of function to DYAD gain skills as they are related to ADL (activities of – In healthcare, a dyad consists of clinical members daily living) and help with a skill that is therapeutic. who co-manage or co-lead an area of responsibility. LABORATORY TECHNOLOGIST GROUP ¾ Examines and study specimens – Two or more people who have shared needs and ¾ Also known as medical technologist goals RADIOLOGIST – Groups exist to help people achieve goals (outcomes) that would be unattainable by individual effort alone ¾ Assist with wide variety of x-ray procedures. GROUP DYNAMICS PHARMACIST ¾ The communication that takes place between ¾ Prepares and dispenses pharmaceuticals in hospitals members of any group and community settings ¾ Open communication is very vital in the group or any ¾ Responsible in preparing and dispensing medications collaboration in the hospitals and community RESPIRATORY THERAPIST ¾ The unique dynamics of each group will influence its maturation or group process, as well as the ¾ Skilled in therapeutic measures used in care of effectiveness of the group. patients with respiratory problems. ¾ Three main functions are required for any group to be ¾ Facilitating nebulization, operation of mechanical effective. ventilators (most especially for clients admitted in the TEAM ICU) ¾ Delivery of coordinated care to individual clients by a PSYCHOLOGIST group of healthcare providers ¾ Looks into the psychological dimension of a person HEALTH CARE TEAM and how health care services are planned ¾ Group of persons who share a common objectives SOCIAL WORKER determined by community needs and toward the ¾ Provides assistance in the problems such as finances achievement of which each member of the team and counselling to the family and patient. contributes in accordance with his competencies MULTIDISCIPLINARY TEAM ¾ An example of these teams at work can be seen in ¾ Multidisciplinary teams are comprised of healthcare many ICUs (intensive care unit). The team is team members from various specialty areas with comprised of the intensivist/physician, a pharmacist, complementary skills, expertise, and experience. nursing, respiratory therapy, social service and, if ¾ It has been established that the utilization of applicable, a family member or the patient. multidisciplinary teams produces higher quality, patient-centered care. ¾ The process by its design should improve communication, collaboration, and collegiality among members of the healthcare team and the patient. ¾ Multidisciplinary team is vital because each of the members of the team has certain or unique expertise RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  or skills that would contribute to the well-being of the o The nurse manager also delegates nursing client activities to ancillary workers and other End of pre-finals…. nurses, and supervises and evaluates their ROLES OF A NURSE performance ¾ CAREGIVER ¾ CASE MANAGER o assist the client physically and o Nurse case managers work with the psychologically while preserving the client’s multidisciplinary health care team to dignity measure the effectiveness of the case o The required nursing actions may involve full management plan and to monitor outcomes care for the completely dependent client, o Case managers help ensure that care is partial care for the partially dependent client, oriented to the client, while controlling costs and supportive-educative care to assist ¾ RESEARCH CONSUMER clients in attaining their highest possible level o Nurses often use research to improve client of health and wellness care o Caregiving encompasses the physical, ¾ EXPANDED CAREER ROLES psychosocial, developmental, cultural, and o Nurses are fulfilling expanded career roles, spiritual levels such as those of NP, clinical nurse specialist, ¾ COMMUNICATOR nurse midwife, nurse educator, nurse o In the role of communicator, nurses identify researcher, and nurse anesthetist, all of client problems and then communicate these which allow greater independence and verbally or in writing to other members of the autonomy health care team o The nurse must be able to communicate clearly and accurately in order for a client’s CONCEPT OF LEADERSHIP & MANAGEMENT health care needs to be met ¾ TEACHER ROLES OF A NURSE AS A MANAGER/LEADER o Helps clients learn about their health and the 1. INTERPERSONAL ROLE health care procedures they need to perform ¾ As a SYMBOL: Consists of duties like to restore or maintain their health signing of papers/documents required by the o The nurse assesses the client’s learning organization needs and readiness to learn, sets specific ¾ As a LEADER: Hires, trains, encourages and learning goals in conjunction with the client, judges enacts teaching strategies, and measures ¾ As a LIAISON: Acts as contact outside the learning community ¾ CLIENT ADVOCATE o A client advocate acts to protect the client. In 2. INFORMATIONAL ROLE this role the nurse may represent the client’s ¾ Monitors information needs and wishes to other health ¾ Disseminates information from both external professionals, such as relaying the client’s and internal sources request for information to the health care ¾ Spokesperson or representative of the provider organization o They also assist clients in exercising their 3. DECISIONAL ROLE rights and help them speak up for themselves ¾ Entrepreneur or innovator, problem ¾ COUNSELOR discoverer, a designer to improve projects o Counseling is the process of helping a client ¾ Troubleshooter to recognize and cope with stressful ¾ Negotiator when conflicts arise psychological or social problems, to develop POSITIVE PRACTICE ENVIRONMENT improved interpersonal relationships, and to ¾ Are settings that support excellent and decent work promote personal growth ¾ An environment that is safe, empowering, and o involves providing emotional, intellectual, satisfying (ANA, 2016) and psychological support ¾ An environment that optimally promotes the physical, o nurse counsels primarily healthy individuals mental, and social well-being of the nurses (WHO) with normal adjustment difficulties and ¾ Work environment focus: Job satisfaction and intent to focuses on helping the person develop new stay (Al-Hamdan, 2017) attitudes, feelings, and behaviors by ¾ ELEMENTS: encouraging the client to look at alternative o Occupational health, safety and wellness behaviors, recognize the choices, and policies that address workplace hazards, develop a sense of control discrimination, physical and psychological ¾ CHANGE AGENT violence and issues pertaining to personal o assisting clients to make modifications in security. their behavior o Fair and manageable work loads and job ¾ LEADER demands o assisting clients to make modifications in o Organizational climate reflective of effective their behavior management and leadership practices, good ¾ MANAGER peer support, worker participation in o The nurse manages the nursing care of decisionmaking, shared values individuals, families, and communities o Healthy work-life balance. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  or skills that would contribute to the well-being of the o The nurse manager also delegates nursing client activities to ancillary workers and other End of pre-finals…. nurses, and supervises and evaluates their ROLES OF A NURSE performance ¾ CAREGIVER ¾ CASE MANAGER o assist the client physically and o Nurse case managers work with the psychologically while preserving the client’s multidisciplinary health care team to dignity measure the effectiveness of the case o The required nursing actions may involve full management plan and to monitor outcomes care for the completely dependent client, o Case managers help ensure that care is partial care for the partially dependent client, oriented to the client, while controlling costs and supportive-educative care to assist ¾ RESEARCH CONSUMER clients in attaining their highest possible level o Nurses often use research to improve client of health and wellness care o Caregiving encompasses the physical, ¾ EXPANDED CAREER ROLES psychosocial, developmental, cultural, and o Nurses are fulfilling expanded career roles, spiritual levels such as those of NP, clinical nurse specialist, ¾ COMMUNICATOR nurse midwife, nurse educator, nurse o In the role of communicator, nurses identify researcher, and nurse anesthetist, all of client problems and then communicate these which allow greater independence and verbally or in writing to other members of the autonomy health care team o The nurse must be able to communicate clearly and accurately in order for a client’s CONCEPT OF LEADERSHIP & MANAGEMENT health care needs to be met ¾ TEACHER ROLES OF A NURSE AS A MANAGER/LEADER o Helps clients learn about their health and the 1. INTERPERSONAL ROLE health care procedures they need to perform ¾ As a SYMBOL: Consists of duties like to restore or maintain their health signing of papers/documents required by the o The nurse assesses the client’s learning organization needs and readiness to learn, sets specific ¾ As a LEADER: Hires, trains, encourages and learning goals in conjunction with the client, judges enacts teaching strategies, and measures ¾ As a LIAISON: Acts as contact outside the learning community ¾ CLIENT ADVOCATE o A client advocate acts to protect the client. In 2. INFORMATIONAL ROLE this role the nurse may represent the client’s ¾ Monitors information needs and wishes to other health ¾ Disseminates information from both external professionals, such as relaying the client’s and internal sources request for information to the health care ¾ Spokesperson or representative of the provider organization o They also assist clients in exercising their 3. DECISIONAL ROLE rights and help them speak up for themselves ¾ Entrepreneur or innovator, problem ¾ COUNSELOR discoverer, a designer to improve projects o Counseling is the process of helping a client ¾ Troubleshooter to recognize and cope with stressful ¾ Negotiator when conflicts arise psychological or social problems, to develop POSITIVE PRACTICE ENVIRONMENT improved interpersonal relationships, and to ¾ Are settings that support excellent and decent work promote personal growth ¾ An environment that is safe, empowering, and o involves providing emotional, intellectual, satisfying (ANA, 2016) and psychological support ¾ An environment that optimally promotes the physical, o nurse counsels primarily healthy individuals mental, and social well-being of the nurses (WHO) with normal adjustment difficulties and ¾ Work environment focus: Job satisfaction and intent to focuses on helping the person develop new stay (Al-Hamdan, 2017) attitudes, feelings, and behaviors by ¾ ELEMENTS: encouraging the client to look at alternative o Occupational health, safety and wellness behaviors, recognize the choices, and policies that address workplace hazards, develop a sense of control discrimination, physical and psychological ¾ CHANGE AGENT violence and issues pertaining to personal o assisting clients to make modifications in security. their behavior o Fair and manageable work loads and job ¾ LEADER demands o assisting clients to make modifications in o Organizational climate reflective of effective their behavior management and leadership practices, good ¾ MANAGER peer support, worker participation in o The nurse manages the nursing care of decisionmaking, shared values individuals, families, and communities o Healthy work-life balance. RN 2025 | Antiporda, Babaran, Ballesta, Cabaccan, Collado, Foronda, Gayanilo, Liñan  o Equal opportunity and treatment. o Opportunities for professional development CPD CYCLE and career advancement. o Professional identity, autonomy and control over practice. o Job security. o Decent pay and benefit o Safe staffing levels. o Support and supervision. o Open communication and transparency. o Recognition programmes. o Access to adequate equipment, supplies and support staff. ¾ CHARACTERISTICS: o Demands that fit the resources of the person o A high level of predictability o Good social support o Meaningful work CAREER STAGES ACCORDING TO SHIRLEY (2009) o A high level of influence PROMISE o A balance between effort and reward ¾ Earliest of the career phase, reflects the first 10 years CONCEPT OF CONTINUING PROFESSIONAL of nursing employment DEVELOPMENT ¾ Individuals are less experienced and tend to LIFELONG LEARNING experience reality overload as a result ¾ It is a process that represents both a value of the ¾ Making wise early career choices is critical health professionals and a complex, critical ¾ Milestones: socialization, building knowledge, skills, competency of health professionals. abilities, credentials, and education base ¾ IMPORTANCE: ¾ Positioning for the future MOMENTUM o The nurses have a professional, moral, and legal responsibility to obtain and ¾ Middle career phase, reflects the nurse with 11 to 29 demonstrate continuing education and years of experience lifelong learning throughout their career. ¾ Nurses in this phase are experienced clinicians with o It is essential to maintain competence to expert knowledge, skills, abilities, credentials, and practice nursing safely and ethically. education base o To prevent substandard care and contribute ¾ This is time for accomplishment, challenge, and a to safe and quality nursing practice. sense of purpose, and the individual often achieves ¾ BARRIERS TO LIFELONG LEARNING: high enough level of expertise to be a role model o Lack of perceived need for continuing ¾ Milestones: building confidence in one’s competence, education developing experience, gaining mastery, establishing o Time constraints professional track record, finding voice through o Lack of confidence in one’s learning ability strengths o Professional disengagement ¾ Most significant challenge: creating possibilities for o Cost career progression o Lack of employer support HARVEST ¾ Nurses with 30 to 40 years as having prime ¾ QUALITIES OF LIFELONG LEARNING experience and nurses with more than 40 years of o Innovative experience as being legacy clinicians. o Flexible ¾ The experiential value of nurses in harvest phase may o Resourceful begin to decline o Change agents ¾ Must actively strive for “reinvention” to renew potential o Shares good practice and knowledge value o Adaptable ¾ Milestones: elevating mastery for advancing the o Challenging and creative profession, positioning as a professional o Self-reliant statesperson, establishing a legacy o Responsible and accountable JUSTIFICATIONS FOR CAREER DEVELOPMENT CAREER DEVELOPMENT 1. Reduces employee attrition ¾ The lifelong series of activities that contribute to a ¾ Reduce turnover of ambitions employees person’s career exploration, establishment, success, 2. Equal employment opportunity and fulfillment. ¾ Better opportunity to move up in an ¾ Members of the profession maintain, improve and organization broaden their knowledge, expertise, and competence 3. Improved use of personnel ¾ It is an ongoing, planned learning and development ¾ People perform better when placed in jobs process that fit them and provide new challenges 4. Improved quality of work life ¾ G