Summary of Nursing Lecture Notes PDF

Rufaidah Al Aslamiyah who was the first nurse in Islam, Lecture.1 Florence Nightingale is the founder of modern nursing. In 1860, She established the Nightingale School of Nursing which was the first school of nursing Definition of Nursing by...

Rufaidah Al Aslamiyah who was the first nurse in Islam, Lecture.1 Florence Nightingale is the founder of modern nursing. In 1860, She established the Nightingale School of Nursing which was the first school of nursing Definition of Nursing by WHO Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Characteristics of Nursing Nursing is caring. Nursing involves close personal contact with the recipient of care. Nursing is concerned with services that take humans into account as physiological, psychological, and sociological organisms. Nursing is committed to promoting individual, family, community, and national health goals in its best manner possible. Nursing is committed to personalized services for all persons without regard to color, creed, social or economic status. Nursing is committed to involvement in ethical, legal, and political issues in the delivery of health care. Recipients of Nursing Care Consumer : an individual, a group of people, or a community that uses a service or a product. Patient: a person who is waiting for or undergoing medical treatment and care. Client: a person who engages the advice or services of another who is qualified to provide this service. Scope of Nursing Practice Nursing practice involves four areas: 1. Promoting health and wellness Engage in activities and behaviors that enhance quality of life and maximize personal potential. 2. Preventing illness Maintain optimal health by preventing disease. 3. Restoring health : Extends from early detection to recovery. Providing direct care Performing diagnostic and assessment procedures Consulting with other health professionals Teaching clients about recovery, exercise, Rehabilitating clients to optimal functional levels. 4. Care for the dying Helping clients live as comfortably as possible till death Helping support persons cope with death. Definition of Nursing Profession  Profession : an occupation that requires extensive education or a calling that requires special knowledge, skill and preparation.  Professionalism : refers to professional character, spirit or methods and implies responsibility and commitment.  Professionalization : the process of becoming a professional by acquiring its characteristics.  Occupation : an activity in which one engages. Criteria of a profession  Ongoing research – increasing research helps develop not only the knowledge base but also contributes to nursing practice.  Code of ethics – ethical codes change based on needs and values of society.  Autonomy – independence at work, responsibility and accountability for one’s actions.  Governance – establishment and maintenance of social, political, and economic arrangements by which practitioners control their practice, self-discipline, working conditions and professional affairs.  Professional organization – nurses need to work within a professional organization as it differentiates a profession from an occupation. Definition of Professional Nurse A professional nurse is a person who has completed a basic nursing education program and is licensed in his country to practice professional nursing. Roles of Professional Nurse  Teacher : provides and interprets information to the patient.  Counselor : provides emotional, intellectual and psychological support to the patient.  Change agent : Initiate changes or assist clients to make modifications in themselves or in the system of care.  Client Advocate : provides explanation in client’s language and support client’s decisions  Manager : Makes decisions and coordinates activities of others  Researcher : Participates in identifying significant researchable problems. Additionally, must be aware of the research process and language of research Definitions : Lecture.2 Health is the state of complete physical, mental and social well-being and not merely the absence of disease. Health promotion is the process of enabling people to increase control over, and to improve, their health. Prevention is defined as actions aimed at eradicating, eliminating, or minimizing the impact of disease Disease prevention specific, population-based and individual-based interventions for primary and secondary (early detection) prevention Approaches to health promotion in nursing practice : 1. Medical or preventive approach : focuses on reducing morbidity and mortality. 2. Behavioral approach : aims to inspire individuals to adopt healthy lifestyle behaviors 3. Educational approach : provide information and facts, and to develop relevant skills so that individuals can make knowledgeable choices about their health. 4. The empowerment approach : focuses on helping people develop decision-making and problem-solving skills and encouraging them to engage in critical thinking and critical action. 5. Social change approach : is concerned with adjusting the physical, social, and financial environment Role of the nurse in Health Promotion : 1. Model healthy lifestyle 2. Assist individuals, families, and communities to increase levels of health 3. Teach client self-care strategies 4. Educate clients to be effective health care consumers 5. Assist clients, families, and communities to develop and choose health-promoting options 6. Reinforce clients’ personal and family health-promoting behaviors 7. Advocate in the community for changes that promote a healthy environment Steps for Developing and Implementing a health promotion program for the community : 1. Management of the plan. 2. Conduct a situation analysis. 3. Identify the goals, target population, and desired outcomes. 4. Identify strategies, activities,, process objectives, and resources. 5. Develop indicators. 6. Review the program plan. 7. Implement the plan/Program. 8. Results and impact. Levels of prevention : Three levels of prevention 1. Primary prevention: The action taken prior to the onset of disease, which removes the possibility that the disease will ever occur. Primary prevention may be accomplished by measures of "Health promotion" and "specific protection" 2. Secondary prevention: focuses on early identification of health problems, prompt intervention to alleviate health problems. 3. Tertiary prevention: It is used when the disease process has advanced beyond its early stages. Role of the Nurse in Preventative Health Care : 1. Regular exercise : 2. Weight management 3. Avoidance of smoking and drug abuse: 4. Moderated alcohol use 5. Control of existing diseases   In 1958, Ida Jean Orlando began developing the nursing process still evident in nursing care today. Lecture.3 Definition of Nursing Process : A process is a series of steps or acts that lead to accomplishment of some goal or purpose. The nursing process is a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient-focused care. Purpose of Nursing Process  Identify the client’s health status and actual or potential health care problems or needs (through assessment).  Establish plans to meet the identified needs.  Deliver specific nursing interventions to meet those needs.  Apply the best available caregiving evidence and promote human functions and responses to health and illness.  Protect nurses against legal problems related to nursing care when the standards of the nursing process are followed correctly.  Help the nurse perform in a systematically organized way their practice.  Establish a database about the client’s health status, health concerns, response to illness, and the ability to manage health care needs. Characteristics of Nursing Process  Patient-centered: by keeping the patient’s right to practice informed decision-making and maintaining patient-centered engagement in the health care setting.  Interpersonal. It involves the interaction between the nurse and the patient with a common goal.  Collaborative. The nursing process promoting open communication, mutual respect, and shared decision-making to achieve quality patient care.  Dynamic and cyclical. In which each phase interacts with and is influenced by the other phases.  Requires critical thinking. Which is a vital skill required for nurses in identifying client problems and implementing interventions to promote effective care outcomes. Components of Nursing Process 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation 1. Assessment "What data is collected?"  The first phase of the nursing process that involves several steps: 1. Data collection from a variety of sources. 2. Data validation. Is a critical step in data collection to prevent misunderstandings, and avoid incorrect inferences and conclusions. 3. Organizing the data. Grouping of related information (data that are collected must be organized to be useful to the health care professional 4. Data interpretation (Data analysis). To Distinguish between relevant and irrelevant data. 5. Making initial inferences or impressions. 6. Recording or reporting data. Assessment data must be recorded and reported. The nurse must make a judgment about which data are to be reported immediately and which data need only to be recorded at that time. Types of Assessment : i. Comprehensive assessment :  Provide baseline of client data including a complete health history and current needs assessment.  Usually completed upon admission to health care agency. ii. Focused assessment:  Is limited to potential health care risks or particular need.  There are not as a detailed as comprehensive assessment.  Often used when short stays are anticipated (e.g., outpatient surgery and emergency departments). iii. Ongoing assessment:  Follow up , or monitoring of specific problems.  Systematic monitoring allows the nurse to determine the clients response to nursing interventions and to identify any other problems. Types of Data collected by assessment methods :  Objective Data “Signs”: observable and measurable facts such as vital signs, height and weight, lung sounds, vomiting, distended abdomen, presence of edema, skin color...etc.  Subjective Data “Symptoms”: information that only the client feels and can describe such as nausea, pain, numbness, pruritus...etc. Sources of Data collected by assessment methods :  Primary sources: the client should be considered the primary source of data. As much information as possible should be gathered from the client, using both interview techniques and physical examination skills.  Secondary sources: data source from other than the client are considered secondary sources (family members, other health care providers, and medical records). 2. Diagnosis: “What is the problem?”  Nursing diagnosis: Is a clinical judgment about individual, family, or community responses to actual or potential health problems  Diagnosing involves analyzing data, identifying health problems, risks, and strengths, and formulating diagnostic statements about a patient’s potential or actual health problem. Difference between Nursing and Medical diagnosis :   Nursing diagnosis contains 3 parts (PES) : 1. Problem: Name of the health-related issue or problem as identified in the NANDA list (North American Nursing Diagnosis Association) 2. Etiology: (identified with the phrase Related to) 3. Sign and symptom (are identified with the phrase “as manifested by” or “ as evidenced by”) Types of Nursing Diagnoses: 1. Actual nursing diagnosis (Actual problems):  Indicates that a problem exists.  Composed of (diagnostic label, related factors, and signs and symptoms).  Example (Impaired Skin Integrity related to prolonged pressure on bony prominence as manifested by stage II pressure ulcer over coccyx, 3 cm in diameter). Examples of Actual Nursing Diagnoses :  Ineffective Breathing Pattern (dyspnea) related to accumulation of fluid in the abdomen secondary to ascites as evidenced by pursed-lip breathing and use of accessory muscles to breath. 2. Risk nursing diagnosis (Potential problems) :  Indicates that a problem does not yet exist, but special risk factors are present.  Is composed of the diagnostic label preceded by the phrase “risk for” with the specific risk factors listed.  An example of a risk diagnosis is: (Risk for Impaired Skin Integrity related to inability to turn self from side to side in bed). 3. Planning  Based on the assessment and diagnosis, the nurse sets measurable and achievable goals for the patient.  The planning phase (Nursing Care Plan) involves several tasks : a) Establishing priorities of nursing diagnoses. b) Setting goals and developing expected outcomes c) Planning nursing interventions d) Record the entire nursing care plan in the client record. 4. Implementation “Putting the plan into action!”  It consists of performing nursing activities that have been planned to meet the goals set with the client. Process of Implementation : 1. Ongoing assessment: Prior to implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed. 2. Determining the nurse’s need for assistance: the nurse may need assistance when implementing some nursing intervention, such as ambulating an unsteady obese client. 3. Implementing the nursing interventions Nursing interventions are grouped into three categories according to the role of the healthcare professional involved in the patient’s care:  Independent Nursing Interventions (nurse initiated): any action the nurse can initiate without direct supervision, e.g. routine nursing tasks such as checking vital signs  Dependent Nursing Interventions: Some actions require guidance or supervision from a physician or other medical professional, such as; prescribing new medication, inserting and removing a urinary catheter  Interdependent Nursing Interventions (Collaborative) : Nursing action performed jointly with other health care team members such as; post-surgery, the patient’s recovery plan may require prescription medication from a physician, feeding assistance from a nurse, and treatment by a physical therapist 4. Supervising the delegated care Delegate specific nursing interventions to other members of the nursing team as appropriate. Consider the capabilities and limitations of the members of the nursing team and supervise the performance of the nursing interventions. 5. Documentation of interventions and client response. 5. Evaluation “Did the plan work  It Involves determining whether the goals have been met, partially met, or not met. Steps in Evaluation : 1. Collecting Data: Data must be documented concisely and accurately to facilitate the next part of the evaluating process. 2. Comparing Data with Desired Outcomes: identify whether the goal was met (when the client response is the same as the desired outcome), partially met (when the desired goal was incompletely attained), or not met. 3. Analyzing Client’s Response Relating to Nursing Activities: determine whether the nursing activities had any relation to the outcomes whether it was successfully accomplished or not. 4. Identifying Factors Contributing to Success or Failure: For example, the client’s family may or may not be supportive, or the client may be uncooperative to perform such activities. 5. Continuing, Modifying, or Terminating the Nursing Care Plan Definition : A nursing care plan (NCP) is a formal process that correctly identifies existing needs and Lecture.4 recognizes a client’s potential needs or risks. Types of NCP : Care plans be : Informal nursing care plan : is a strategy of action that exists in the nurse‘s mind. Formal nursing care plan is a written or computerized guide that organizes the client’s care information and divided into: 1 Standardized care plans are pre-developed guides by the nursing staff and health care agencies to ensure that patients with a particular condition receive consistent care. 2 Individualized care plan care plan involves tailoring a standardized care plan to meet the specific needs and goals of the individual. Additionally, individualized care plans can improve patient satisfaction. When patients feel that their care is tailored to their specific needs, they are more likely to feel heard and valued, leading to increased satisfaction with their care. This is particularly important in today’s healthcare environment, where patient satisfaction is increasingly used as a quality measure. Purposes of NCP : 1. Defines nurse’s role. 2. Provides direction for individualized care of the client. 3. Continuity of care : Nurses from different shifts or departments can use the data. 4. Coordinate the care : Ensures that all members of the healthcare team are aware of the patient’s care needs and the actions that need to be taken to meet those needs to prevent gaps in care. 5. Documentation : If nursing care is not documented correctly in the care plan, there is no evidence the care was provided. 6. Serves as a guide for assigning a specific staff to a specific client. There are instances when a client’s care needs to be assigned to staff with particular and precise skills. 7. Monitor progress : To help track the patient’s progress and make necessary adjustments to the care plan as the patient’s health status and goals change. 8. Defines client’s goals : It benefits nurses and clients by involving them in their treatment and care. Components of NCP : 1. Client health assessment, medical results, and diagnostic reports are the first steps to developing a care plan. Information in this area can be subjective and objective. 2. Nursing diagnosis : is a statement that describes the patient’s health issue or concern. It is based on the information gathered about the patient’s health status during the assessment. 3. Expected client outcomes : these are specific goals that will be achieved through nursing interventions. These may be long and short-term. 4. Nursing interventions: these are specific actions that will be taken to address the nursing diagnosis and achieve expected outcome. They should be based on best practices and evidence-based guidelines. 5. Rationales: these are evidence-based explanations for the nursing interventions specified. 6. Evaluation: these includes plans for monitoring and evaluating a patient’s progress and making necessary adjustments to the care plan as the patient’s health status and goals change. Format of NCP :  Nursing care plan formats are usually categorized or organized into four columns: (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation.  Some agencies use a three-column plan where goals and evaluation are in the same column.  Other agencies have a five-column plan that includes a column for assessment cues. Steps of developing NCP : Step 1: Data Collection or Assessment  The first step in writing a nursing care plan is to create a client database using assessment techniques and data collection methods (physical assessment, health history, interview, medical records review, and diagnostic studies).  In this step, the nurse can identify the related or risk factors and defining characteristics that can be used to formulate a nursing diagnosis.  Step 2: Data Analysis and Organization  Analyze, cluster, and organize the data to formulate your nursing diagnosis, priorities, and desired outcomes. Step 3: Formulating Your Nursing Diagnoses  NANDA nursing diagnosis are a uniform way of identifying, focusing on and dealing with specific client needs and responses to actual and high-risk problems. Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnosis.  Common NANDA nursing diagnosis examples that can be use to develop nursing care plans:  Activity Intolerance (Decreased Activity Tolerance)  Acute Pain  Anxiety Chronic Pain Imbalanced Nutrition: Less Than Body Requirements Constipation Impaired Skin Integrity Deficient Fluid Volume Risk for Impaired Skin Integrity Deficient Knowledge Impaired Urinary Elimination Diarrhea Ineffective Airway Clearance Excess Fluid Volume Ineffective Breathing Pattern Fatigue Ineffective Tissue Perfusion Fear Risk for Falls Grieving Risk for Infection Impaired Gas Exchange Risk for Injury Step 4: Setting Priorities  In this step, the nurse and the client begin planning which nursing diagnosis requires attention first. Diagnoses can be ranked and grouped as having a high, medium, or low priority. Life-threatening problems should be given high priority.  Physiological and safety needs are the basis for implementing nursing care and interventions. Thus, they are at the base of Maslow’s pyramid, laying the foundation for physical and emotional health. Step 5: Establishing Client Goals and Desired Outcomes  After assigning priorities for nursing diagnosis, the nurse and the client set goals for each determined priority.  Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions derived from the client’s nursing diagnosis.  Goals provide direction for planning interventions, serve as criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement. Short-term goals:  Developed from the problem portion of the diagnostic statement  Outcomes achievable in a few days or 1 week  Client-centered  Measurable  Realistic Long-term goals:  Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems Components of goals and desired outcomes:  Subject: is the client, any part of the client, or some attribute of the client (i.e., pulse, temperature, urinary output).  Verb: The verb specifies an action the client is to perform, for example, what the client is to do, learn, or experience.  Conditions or modifiers: these are the “what, when, where, or how” that are added to the verb to explain the circumstances under which the behavior is to be performed.   Criterion of desired performance: indicates the level at which the client will perform the specified behavior. These are optional. Tips for writing goals and desired outcomes:  Begin each goal with “Client will […]” help focus the goal on client behavior and responses.  Use observable, measurable terms for outcomes. Avoid using vague words that require interpretation or judgment of the observer.  Desired outcomes should be realistic for the client’s resources, capabilities, limitations, and on the designated time span of care.  Ensure that each goal is derived from only one nursing diagnosis.  Lastly, make sure that the client considers the goals important and values them to ensure cooperation. Step 6: Selecting Nursing Interventions  Nursing interventions are activities or actions that a nurse performs to achieve client goals.  Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis.  As for risk nursing diagnoses, interventions should focus on reducing the client’s risk factors.  In this step, nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the implementation step. Tips for writing Nursing intervention:  Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Action verb starts the intervention and must be precise.  Use only abbreviations accepted by the institution.  Nursing interventions should be: o Safe and appropriate for the client’s age, health, and condition. o Achievable with the resources and time available. o Inline with the client’s values, culture, and beliefs. o Inline with other therapies. Step 7: Providing Rationale  Rationales, also known as scientific explanations, explain why the nursing intervention was chosen for the NCP.  Rationales do not appear in regular care plans. They are included to assist nursing students in associating the pathophysiological and psychological principles with the selected nursing intervention. Step 8: Evaluation  Evaluation is an essential aspect of the nursing process because the conclusions drawn from this step determine whether the nursing intervention should be terminated, continued, or changed. Step 9: Putting it on Paper  The client’s care plan is documented according to hospital policy and becomes part of the client’s permanent medical record, which may be reviewed by the oncoming nurse. Definition of Nursing Theory Lecture.5 Theory is a proposed body of belief, policy or procedure that is followed as basis for action. Nursing theories are guidelines, providing immeasurable knowledge to nursing professionals that in turn direct nursing care and practices, both broad and specific. Purpose of Nursing Theories : Nursing theories are developed to define and describe nursing care, guide nursing practice, and provide a basis for clinical decision-making: 1. In Academic Discipline: the purpose is to explain the fundamental implications of the profession and enhance the profession’s status. 2. In Research: the it is necessary to use theory as a framework to provide perspective and guidance to the research study. 3. In Profession: Clinical practice generates research questions and knowledge for theory. In a clinical setting, its primary contribution has been the facilitation of reflecting, questioning, and thinking about what nurses do. Metaparadigms and main concepts of Nursing Theories : Many nurse theorists have put forth a variety of nursing theories that are still relevant in nursing care. (e.g., Florence Nightingale’s Environment theory, Imogene King’s Theory of Goal, etc.). Despite the number, all nursing theories follow a set of guidelines or what we call Metaparadigms. Metaparadigms : are a collective set of concepts enlisted to provide structure in any given discipline. The nursing paradigms employs four parts main concepts of Nursing theories that correlate in the holistic approach of nursing care : 1. Person : also known as the Client/ Patient/Human being. A person is the recipient of nursing care and may be individuals, groups, or communities. Out of the four ideas, the Person is the most important for it signifies the patient himself. 2. Environment : also known as the situation. It is the external or internal environmental aspect that will affect the Person. This includes the positive or negative conditions, the actual physical setting, (family, significant others), and the setting for access to health care. 3. Health : is defined as the level of wellness that the Person is already subjected to. 4. Nursing : the nursing care provided to the patient. Components of Nursing Theories : There are various parts for a theory to be considered a theory : 1. Phenomenon: It is the term coined to define any nursing-centric response to a given situation, event, or process (may it be single or a group), that is either temporary or permanent. 2. Concepts : define a nursing theory. They are utilized to describe and give a clearer picture of the phenomena. 3. Definitions: are general statements used to put forth the main concepts of a nursing theory, as: Theoretical definitions are given by the nursing theorist based on his/her perspective and understanding. Operational definitions are definitions of how these concepts are measured. 4. Relational Statements: these are links that connect and define two or more concepts, showing the relationships of these concepts and how they signify to the theory as a whole. 5. Assumptions : they are educated and accepted truths that explain the totality of a nursing theory, including concepts, relationships, definitions, structure, etc. Classifications of Nursing Theories: Nursing theories can be classified according to their function, abstraction levels, or orientation of goals : I. Types of Nursing Theories By Abstraction 1. Grand Nursing theories : Broad in scope, complex, require specification. For Example, the Environmental theory by Florence Nightingale. 2. Middle range Nursing theories : they are more limited in scope, comparing to grand nursing theories. For example, the Interpersonal Relations Theory by Hildegard Peplau. 3. Practice level Nursing Theories : The scope of these types of theories are narrow. It provide the basis for nursing interventions rendered in the nursing practice. For example, the Theory of Care transition by Afaf Meleis. II. Types of Nursing Theories By Goal Orientation 1. Descriptive Theories : are regarded as the first level in theory development, with the aim of detailing the components of a nursing phenomenon as it occurs. 2. Prescriptive Theories: aim to address nursing practice for a phenomenon, consequently opening changes and predicting effects of these changes. Nursing Theories in Practice :  Nursing theories assists and guide advanced practice nurses, nursing researchers, and nurse educators in their practice of nursing and therefore, would push impactful contributions to the profession.  Nursing theories can: 1. Generate nursing knowledge for use in practice 2. Direct how to use nursing process 3. Are adaptable to different patients and all care settings Famous Nursing Theories and Theorists : I. Florence Nightingale Nursing Theory:  She is the founder of Modern Nursing and the author of the Environmental Theory  In this theory, Nightingale stated that Nursing is “the act of using the patients’ environment in order to assist in bringing back his health.”  Furthermore, she identified five environmental factors that affecting the recovery and health of the patient and they are fresh air, pure water, efficient drainage systems, proper sanitation, and sunlight. II. Hildegard Peplau Nursing Theory :  She is the author of the Theory of Interpersonal Relations which defined Nursing as “An interpersonal process of varied interactions between an individual who is in need of health services and a nurse trained specifically to address these concerns in the most therapeutic way possible.  This theory enables nurses to formulate and enforce more therapeutic interventions that are more impactful in the clinical setting. III. Virginia Henderson Nursing Theory:  She is the author of the Nursing Needs Theory  Her theory states that patients must attain and satisfy 14 needs, through the help of the nurse in order to gain independence and regain back their health: 1. Breathe normally 2. Eat and drink adequately 3. Eliminate body wastes 4. Move and maintain desirable postures 5. Sleep and rest 6. Select suitable clothes; ability to dress and undress 7. Maintain body temperature within normal parameters 8. Keep the body clean and protected 9. Avoid dangers in the environment to safeguard self and others 10. Communicate with others of fears, emotional needs, and opinions. 11. Worship according to one’s belief system 12. Work fulfillment that brings up a sense of accomplishment 13. Play and participate in healthy recreational activities 14. Learn and satisfy curiosity as part of normal development and the use of these health facilities to address these concerns. IV. Ida Jean Orlando Nursing Theory :  She is the author of the Nursing Process Theory.  Her theory allowed nurses to formulate effective and efficient nursing care plans.  The theory also states that individuals become patients, that would be dependent on nursing care when they are unable to fulfill their activities independently because of body limitations.  The nurse’s goal is to correctly identify and address the patient’s health care needs. IV. Dorothea Orem Nursing Theory :  Dorothea Orem developed the Self Care Theory where in Nursing is described as “The act of assisting others on their self-care needs in order to maintain optimal human function effectiveness.”  The main focus is the individual’s self-determination in providing self-care. Documentation is the professional responsibility of all health care practitioners. Lecture.6 Effective documentation requires clear, concise, accurate recording of all client care and other significant events in an organized manner. Documentation is defined as written evidence of: The interactions between and among health professionals, clients, their families, and health care organizations. The administration of tests, procedures, treatments, and client education The results or client’s response to these diagnostic tests and interventions. Definition of Reporting: is the oral, written, computer based communication intended to convey data regarding the client’s (health status, needs, treatments, outcomes, and responses) to others health team members. Classification of Reports: Oral report : are given when the information is for immediate use and not for permanency. Written report: Reports are to be written when the information is to be used by several person , which is more or less of permanent value Purposes of Health Care Documentation: 1. Professional responsibility and accountability: documentation provides written evidence of the practitioner’s accountability to client, institution, and society 2. Communication: Reporting and recording are the major communication techniques used by health care providers to direct continuity of care and to validates the care provided to the client. 3. Education: Client’s medical record can be used for the purpose of education. Nursing students use medical record as a tool to learn about disease processes, complications, medical and nursing diagnoses, and interventions. 4. Research: Researchers rely heavily on clients’ medical records as a clinical data source to determine if clients meet the research criteria of a study. 5. Meeting legal and practice standards: Client’s medical record is a legal document, and in the case of a lawsuit the record serves as the description of exactly what happened to a client. Methods of Documentation: 1. Narrative Charting: It is the traditional method of nursing documentation. Is a story format that describes the client’s status, interventions & treatments, and the client’s response to treatments. Easy to use in emergency situations, in which a simple, chronological order is needed 2. Source-Oriented Charting: Is described as a narrative recording by each member (source) of the health care team on separate records. Because each discipline has a separate record, care is often fragmented and communication between disciplines becomes time-consuming. 3. Problem-Oriented Charting: Documentation is on the client’s problem, with a structured, logical format to narrative charting called SOAPIE: - S: subjective data - O: objective data - A: assessment - P: plan - I: intervention - E: evaluation 4. PIE Charting: is an acronym for problem, intervention, and evaluation of nursing care (PIE) 5. Focus Charting: A method of identifying and organizing the narrative documentation of client concerns to include data, action, and response. This method is not limited to client “problems” but allows for the identification of all “concerns” such as a significant event (e.g., results of a diagnostic test). 6. Charting by exception (CBE): The CBE system has three key components:  Flow sheets: Highlight significant findings and define assessment parameters and findings.  Reference documentation: Is related to the standards of nursing practice.  Bedside accessibility: Is related to the documentation forms. 7. Computerized Documentation: it facilitate speed in communication, accuracy in information, capability of information storage, data retrieval, and data revision. 8. Case Management Process: A methodology for organizing client care through an episode of illness so that specific clinical and financial outcomes are achieved within an allotted time frame.  Forms of Medical Record Documents : Document Information Face sheet Biographical data: name, date of birth, address, phone number, marital status, employment, gender, religion, closest relative; insurance coverage; allergies; admitting medical diagnosis;; statement of whether the client has an advance directive. Admit: Gives the right to treat. Consent form Surgery: Explains the reason for the operation, the risks for complications, and the client’s level of understanding. Blood transfusion: Permission to administer blood or blood products. History & physical Results of the client’s initial history and physical assessment as performed by the examination health care provider. Prescriber order sheet Medical orders to admit and the treatment plan. Progress notes Evaluation of the client’s response to treatment; may contain the progress recording of interdisciplinary practitioners (e.g., dietary or social services) Consultation sheet Initiated by the physician to request the evaluation or services of other practitioners. Diagnostic results Contains the results from laboratory and diagnostic tests (e.g., X-ray, hematology). Nursing admit Recording of data obtained from the interview and physical assessment conducted assessment by the registered nurse. Nursing plan of care Contains the nursing care plan (e.g., nursing diagnosis or a problem list, expected outcome, intervention and evaluation) Graphic sheet Data recording regarding vital signs and weight. Flow sheet Contains all routine interventions that can be noted with a check mark or other simple code; allows for a quick comparison of measurement. Nurses’ progress notes Additional data that do not duplicate information on the flow sheet (e.g., client’s achievement of expected outcome or revision of the plan of care) Medication Contains all medication information for routine and prn drugs: date, time, dose, administration route, site (for injections). record (MAR) Patient education Recording of the nurses’ teaching of the client, family, or other caregiver and the record learner’s response. Discharge plan A multidisciplinary form used before discharge from a health care facility and summary containing a brief summary of care rendered and discharge instructions (e.g., food- drug interactions, referrals or follow-up appointments Guidelines for Good Documentation and Reporting: 1. Fact : information about clients and their care must be factual. 2. Accuracy: information must be accurate so that health team members have confidence in it 3. Completeness: the information within a record or a report should be complete, containing concise and thorough information about a client’s care. 4. Currentness: ongoing decisions about care must be based on currently reported information. At the time of occurrence include the following: a. Vital signs b. Medications Administration and treatments c. Preparation of diagnostic tests or surgery d. Admission, transfer, discharge or death of a client f. Treatment for a sudden change in status 5. Confidentiality: a confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed Definition of Admission: The process of entering a health care agency for nursing care and medical or Lecture.7 surgical treatment. Psychosocial Responses on Admission : 1. Anxiety and fear. 2. Decisional conflict. 3. Situational low self-esteem. 4. Powerlessness. 5. Social isolation. 6. Risk for ineffective therapeutic regimen management. Admission Process : 1. Authorization from a physician that the person requires specialized care and treatment. 2. Completion of the agency’s admission data base by nursing personnel. 3. Documentation of the client’s medical history and findings from physical examination. 4. Development of an initial nursing care plan. 5. Initial medical orders for treatment. Nursing Admission Activities: 1. Preparing the client’s room. 2. Welcoming the client. 3. Orienting the client. 4. Safeguarding valuables and clothing. 5. Helping the client undress. 6. Compiling the nursing data base. Types of Admission : Definition & Purpose of Transfer:  Transfer: discharging a client from one unit or agency; admitting him or her to another without going home.  Purpose : o To obtain special care (intensive care unit) o To obtain a different type of accommodation (single room) Transfer Process: 1. Informing client and family about the transfer. 2. Completing a transfer summary. 3. Speaking with a nurse on the transfer unit to coordinate the transfer. 4. Transporting the client and his or her belongings, medications, nursing supplies, and chart to the other unit Definition of Discharge :  Discharge is the termination of care from a health care agency.  Planning for discharge actually begins on admission, when information about the patient is collected and documented.  The key to successful discharge planning is an exchange of information among the patient, the caregivers, and those responsible for care while the patient is in the acute care setting and after the patient returns home. Discharge Process : 1. Discharge planning:  Assessing and identifying health care needs.  Setting goals with the patient.  Important teaching topics about self-care at home must be covered before discharge.  Meeting eligibility requirements for home health care. 2. Obtaining a written medical order. 3. Completing discharge instructions. 4. Notifying the business office. 5. Helping the client leave the agency. 6. Writing a summary of the client’s condition at discharge. 7. Requesting that the room be cleaned. Referral Process:  A referral is the process of sending someone to another person or agency for special services.  Clients requiring referral : 1. Elderly 2. Children with complex conditions 3. Weak persons who live alone 4. Homes are barriers to safety 5. Lack/Limited support system Definition & Purpose of Home Health Care :  Health care provided in the home by an employee of a home health agency Purpose : 1. Help shorten time spent recovering in hospital. 2. Prevent admissions to extended care facilities. 3. Reduce readmissions to acute care facilities. Importance of nursing health assessment : Lecture.8 1. Systematic and continuous collection of client data 2. It focus on client responses to health problems 3. The nurse carefully examine the client’s body parts to determine any abnormalities 4. The nurse relies on data from different sources which can indicate significant clinical problems 5. Health assessment provides a base line used to plan the clients care 6. Health assessment helps the nurse to diagnose client's problem & the intervention 7. Complete health assessment involves a more detailed review of client’s condition 8. Health assessment influence the choice of therapies & client's responses Purposes of Health Assessment : 1. Gather data 2. Confirm or refuse data obtained in the health history 3. To identify nursing diagnoses 4. To make clinical judgments about client's changing health status 5. To evaluate bio-psycho-social and spiritual outcomes of care Nursing & Medical diagnosis : There is a big Difference between both because: Nursing diagnosis is independent role of the nurse Nursing diagnosis depends on the client's problems / response associated with specific disorder Medical diagnosis depends on clinical picture and laboratory findings The specialist doctor has a right to diagnose not else Example: o DM is medical diagnoses (hypo or hyperglycemia) o Nursing diagnosis in this case e.g. Impaired skin integrity R/T poor circulation, Knowledge deficit about the effects of exercise on needs of insulin. Techniques of Physical Assessment : There are four basic techniques used during physical examination. These techniques should be used in an organized manner from least disturbing or invasive to most invasive to the patient 1. Inspection 2. Auscultation 3. Palpation 4. Percussion Inspection :  Is the most frequently used assessment technique.  Inspection is defined as “the use of the senses of vision, smell and hearing to observe the normal condition or any deviations from normal of various body parts. Principals of Accurate Inspection : 1. Good lightening either day light or artificial light is suitable. 2. Expose body parts being observed only. 3. Look before touching. 4. Warm room for examination of the client “not cold not hot". 5. Observe for color, size, location, texture, symmetry, odors, and sounds. 6. Compare each area inspected with the opposite side of body. 7. Use pen light to inspect body cavities. Auscultation Is the process of listening to sounds produced within the body.  Auscultation is usually performed following inspection, especially with abdominal assessment. The abdomen should be auscultated before percussion or palpation to prevent production of false bowel sounds.  In auscultation, the nurse uses both direct auscultation by listening to body sounds with the unaided ear, and indirect auscultation by using a stethoscope.  Auscultated sounds are described according to their pitch, intensity, duration, and quality.  The pitch is the number of vibrations per second (frequency).  The intensity (amplitude) refers to the loudness or softness of a sound.  The duration of a sound is its length (long or short).  The quality of sound is a subjective description of a sound, for example, gurgling sound  The stethoscope has both a flat disc diaphragm and a bell-shaped amplifier.  The diaphragm best transmits high-pitched sounds like lung sounds, bowel sounds, and some heart sounds.  The bell best transmits low-pitched sounds like some heart sounds, as well as sounds associated with abnormal vascular sounds of the carotid arteries and the aorta Principals of Auscultation : 1. Ensure the exam room is quiet. 2. Auscultate over bare skin, listening to one sound at a time. 3. Auscultation should never be performed over patient clothing or a gown, as it can produce false sounds or diminish true sounds. 4. The bell or diaphragm of the stethoscope should be placed on patient’s skin firmly enough to leave a slight ring on the skin when removed. 5. Use a high-quality stethoscope Steps of proper use of Stethoscope : 1. Begin by explaining the procedure and asking permission to touch. 2. Next, create a quiet environment. 3. Third, cleanse the stethoscope. Clean the entire stethoscope using an alcohol pad on the earpieces and the end piece immediately prior to use. 4. Next, place the earpieces in your ears 5. Last, open or close the diaphragm or bell depending on which end piece you want to use. It is important to tap on the diaphragm to ensure sounds are heard if using the diaphragm or not heard if using the bell. Palpation :  Palpation is the technique of using the hands /fingers to assess the client based on sensation of touch.  There are two types of palpation: light and deep. Deep palpation  Deep palpation is performed with extreme caution because pressure can damage internal organs.  Used to assess abdominal organs/masses  It is usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed.  It is done with one hand or with two. The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensations. Principals of Accurate Palpation : 1. Examiner finger nails should be short. 2. Use sensitive part of the hand. 3. Start with light then deep palpation 4. Tender area are palpated last 5. Tell client to take slow deep breath to enhance muscle relaxation. 6. Examine condition of the abdominal organs 7. Depressed areas must be approximately “2cm” 8. Assess turgor of skin measured by lightly grasping the body part with finger tips. Percussion : is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt.  Percussion is used to determine the size and shape of internal organs by establishing their borders. It indicates whether tissue is fluid filled, air filled, or solid.  There are two types of percussion: direct and Indirect Sounds produced by Percussion : Health history : Lecture.9 I. Present health status:  Obtaining information about a patient’s present health status allows the nurse to investigate current complaints.  The mnemonic, PQRST is used to assess each symptom and after any intervention to evaluate any changes or responses to treatment o P = Provocative or Palliative : S = Severity : On a scale of 1-10, how bad is the symptom(s)? What makes the symptom(s) better or worse? T = Timing : Does it occur in association with something else o Q = Quality : Describe the symptom(s) (i.e. eating, exertion) o R = Region or Radiation II. Past health history :  The past health history should elicit information about the patient’s childhood illnesses and immunizations, accidents or traumatic injuries, hospitalizations, surgeries, psychiatric or mental illnesses, allergies, and chronic illnesses. III. Family history :  It is important in identifying patient’s risk for certain disease states. Review of Systems and Physical Examination : The physical examination is performed in a “head-to-toe” fashion, starting with the head and ending with the toes.