Nursing Process and Critical-Thinking PDF

Nursing Roles 5. Differentiate what one knows 1. Direct care providers from what one merely believes 2. Coordinator of Care 3. Managers...

Nursing Roles 5. Differentiate what one knows 1. Direct care providers from what one merely believes 2. Coordinator of Care 3. Managers Activities which needs Socratic Questioning 4. Educators 1. An end-of-shift report 5. Client Advocates 2. Reviewing a history of progress notes Whatever role nurses takes: The most important responsibility is to 3. Planning care make correct and safe decisions in the variety of client care 4. Discussing a client’s care with situation colleagues. Skills required to fulfill those roles: Socrates - classical Greek philosopher, founder of western Critical - thinking = “decide and solve the problem” philosophy and first moral philosopher. Problem - solving = “the only solution of the problem” Popular Quotes: Decision - making = “the best solution for the problem” 1. An UNEXAMINED life is not worth living. Critical - thinking - an intellectual skill based on theories and 2. True knowledge exist in knowing principles guided by that you KNOW NOTHING. Logic - forces a decision apart from or in opposition to reason. Socrates Methods of Questioning: Intuition - a power to attaining to direct knowledge 1. Questions about the Question (or Problem) without evident rational thought and inference. 2. Questions about Assumptions Creativity - quality of something created not 3. Questions about Point of View imitated. 4. Questions about Evidence and Reasons 5. Questions about Implications and Consequence Knowing how one thinks helps the nurse work collaboratively with other healthcare providers ( Rubenfeld and Scheffer, 2006) Inductive and Deductive Reasoning They: 1. Inductive Reasoning - specific to general 1. Know how to think – means they THINK like a nurse. observation 2. Possess intellectual autonomy – they refuse to accept - generalizations are formed from a set of conclusions without evaluating evidence (facts and specific facts or observations. reasons) - E.g.: premise or specifics: observed from 3. Think beyond the obvious and make connections between one (1) patient. ideas. - Dry skin - -Poor turgor Barriers to creative thinking: - Sunken eyes Internal and External Factors - Dark amber urine Internal: - Generalization: All clients with same s/s - Individual’s perception influenced by physical and are dehydrated. emotional states and by personal characteristics (e.g. values, past experiences interest and 2. Deductive Reasoning - general premise to the knowledge.) specific External: - reasoning from general premise to the - Environmental conditions and time specific conclusion. - Unpredictable events and uncertainty in clinical - Example: settings 1. Generalization: All children eat - Agency policies – dictates a standard format that only one (1) kind of food at a thinking. time. Groupthink 2. Specifics: if the client is a child, - going along with the majority opinion view point she eats one (1) kind of food at Unresolved conflict among team members a time. - So, nurses use critical thinking to help Skills in critical thinking: analyze situations and establish which 1. Critical analysis premises are valid. - is the application of a set of QUESTIONS to a particular situation or idea TO DETERMINE Differentiate types of statements - can help nurses: essential INFORMATION and IDEAS and 1. Evaluate the credibility of information sources DISCARD superfluous information and ideas. 2. Comprehend a client situation clearly. Socratic Questioning – is the technique one can Example: use to: Patient: “I think I have a tumor” 1. Look beneath the surface Nurse: clarifies by asking: “What is your definition of 2. Recognize and examine assumptions a tumor?” 3. Search for inconsistencies Because = tumor is defined by: 4. Examine multiple points of view Medical: as a SOLID MASS Lay: as CANCER Attitudes that foster critical thinking: Breadt Do I need to consider another point Independence - not easily swayed by the opinions of h of view? others but take responsibility for their own views from acquired knowledge and experience. Precisi Can I be more specific? Fair Mindedness - listening to opinions of all the on members of the health team. - Assessing all viewpoints with the Signifi Which of these facts is most same standards and not basing cance important? their judgements on personal or group bias or prejudice. Compl Have I missed any important Insight into Egocentricity - actively trying to examine etenes aspects? their own biases and bring them to awareness each time s they make a decision. Example: Nurses believe that all Fairne Am I considering the thinking of patients are willing to listen to ss others? discharge instructions but mystified when the client appears uninterested. Depth What makes this a difficult problem? Best thing to do: I identify client’s priorities before Nursing Process - Nursing is both a science and an art initiating health teachings. with the following concerns of the individual receiving care: Intellectual Humility - awareness of the limits of one’s 1. Physical own knowledge. Nurses must be willing to: 2. Psychological/Emotional 1. admit what they do not know 3. Sociological 2. Seek new information 4. Cultural 3. rethink their conclusion in light of new knowledge. 5. Spiritual Intellectual Courage to Challenge the Status Quo and Rituals - considering and examining fairly one’s own ideas The SCIENCE of nursing is based on a broad or views especially those to which one may have a strong THEORETICAL framework. negative reaction. The ART depends on the cing skills and abilities of the Values and beliefs: are not always individual nurse (Critical Thinking Skills) acquired rationally. Rational beliefs: are those that have NURSING GUIDELINE TO CRITICAL THINKING AND been examined and found to be PROBLEM SOLVING supported by solid reasons and data. Integrity - applying same rigorous standards of proof to NURSING PROCESS (by Ida Jean Orlando) their own knowledge and beliefs as they apply to the - guide nurses to solve a problem knowledge and beliefs of others. - “deliberate problem solving approach to meeting Perseverance - determination to finding effective solutions the health care and nursing needs of patients” to client and nursing problem. (Nettina, 2009) Example: finding the exact cause of chilling - “roadmap/guideline” to aid in problem solving while dialysis is going on. UC Nurse – used critical thinking: CIRCULAR - meaning, nurses must continue to collect data The patient is using different brand of and make changes as the information dictates. heparin causing chilling sensations. round - can move back and forth or rotate. Confidence - is a faith of belief that one will act in a right, proper, or effective way which is the result of both NURSING PROCESS inductive and deductive reasoning. Goal: Help individualized patient care - There must be standards for evaluating thought. 1. Nursing Process - the systematic framework for Curiosity - being interested in what is not one’s personal providing professional, quality Nursing Care. All or proper concern by asking relevant questions. Nursing activities are directed to: » Promote health – (e.g. STANDARDS OF CRITICAL THINKING exercise) » Protects health – Clarity What is an example of this? Immunization » Restore health – medication Accura How can I found out if that is true? » Provide peaceful death – cy spiritual vision Characteristics of Nursing Process: Releva How does that help me with the 1. Problem Oriented - because it determine its nce issue? problem 2. Goal Oriented - because there is a specific aim to Logical Does that follow from the evidence? solve the problem ness  3. Orderly-planned step by step - because there is a series of - Identify health problems, risks and steps or components needed to achieve the goal strengths 4. Open to accepting additional information during its - Formulate diagnostic statements application. c. Planning 5. Feedback is - Prioritize problems/ diagnoses 6. Phases are interrelated - Formulate goals/desired outcomes 7. Can be viewed from a system and humanistic perspective. - Select nursing interventions 8. Creativity – the continual development of the process. - Write nursing interventions System – sets of interrelated parts that from a unified whole d. Implementation Process – a continuous progression from one point to another to - Reassess the client achieve a specific goal. - Determine the nurse’s need for assistance Requirement for Nursing Process: - Implement the nursing interventions CRITICAL THINKING - a logical pattern of thoughts based on - Supervise delegated care knowledge, experience, problem solving ability and reasoning. It is - Document nursing activities widening of information and selection of relevant information, thus e. Evaluation enables the individual to make decisions in an efficient and effective - Collect data related to outcomes manner, to analyze relationships, to conceptualize and to make - Compare data with outcomes reasoned judgement. - Relate nursing actions to client goals/outcomes TO THINK CRITICALLY IS A SKILL which is developed and refined - Draw conclusions about problem status throughout life. So, young children as well as lack of knowledge and - Continue modify or terminate the clients experience have much to do with it. care plan. Approaches: 1. Systems Approach: the process is viewed as the primary system. Subsystems: Phase and Purpose Activities a. Patient Description b. Nurse c. Component of the ASSESSING: To 1. Obtain a nursing health process. Collecting, establish a history. 2. Humanistic Approach: take into account all that is known organizing, database 2. Conduct a physical about a thoughts, feelings, values, experiences, like, desires, validating, and about the assessment. behavior and body. (Lamonica, 1979) documenting client’s 3. Review client records. client data response 4. Review nursing to health literature. concerns 5. Consult support or illness persons. and the 6. Consult health ability to professionals manage 7. Update data as health care needed. needs. DIAGNOSING To identify 1. Interpret and analyze Analyzing and client data. synthesizing strengths 2. Compare data against data and health standards problems 3. Cluster or group data that can be (generate tentative prevented hypothesis) or resolved 4. Identify gaps and collaborativ inconsistencies. e and 5. Determine client’s independe strengths, risks, nt nursing diagnoses and intervention problems. Components of Nursing Process: s 6. Formulate nursing a. Assessing To develop diagnoses and - Collect Data a list of collaborative problem - Organize Data nursing statements. - Validate data and 7. Document nursing - Document collaborativ diagnosis on the care b. Diagnosing e problems plan. - Analyze Data  Benefits of the Nursing Process for: Nurse: 1. Self-confidence PLANNING: To develop 1. Set priorities and 2. job Satisfaction Determining an goals/outcomes in 3. Professional Growth how to individualiz collaboration with client. prevent, ed care 2. White goals/desired Clients: reduce, or plan that outcomes. 1. Potential for greater participation in their resolve the specifies 3. Select nursing own career. identified client strategies/interventions. 2. Continuity of quality care. priority client goals/desir Consult other health problems; how ed professionals. ANA NUrsing Scope and Standards of Practice to support outcomes, 4. White nursing Standard 1. Assessment client and related interventions and - The registered nurse collects comprehensive data strengths; and nursing nursing care plan pertinent to the client’s health or situation. how to intervention 5. Communicate care plan Standard 2. Diagnosis implement s. to relevant health care - The registered nurse analyzes the assessment nursing providers. data to determine the diagnosis or issues. interventions Standard 3. Outcome Identification in an - The registered nurse identifies expected outcomes organized, for a plan individualized to the client or situation. individualized, Standard 4. Planning and goal- - The registered nurse develops a plan that oriented. describes strategies and alternatives to attain expected outcomes. IMPLEMENTI To assist 1. Reassesses the client Standard 5. Implementation NG: the client to to update the database - The registered nurse implements the identified Carrying out meet 2. Determine the nurse’s plan. (or delegating) desired need for assistance Standard 5A: Coordination of Care and goals/outco 3. Perform planned - The registered nurse coordinates care delivery. documenting mes; nursing interventions Standard 5B: Health Teaching and Health Promotion the planned promote 4. Communicate what - The registered nurse employs strategies to nursing wellness; nursing actions were promote health and a safe environment. interventions prevent implemented Standard 5C: Consultation illness and 5. Document care and - The advanced practice registered nurse and the disease; client nursing role specialist provide consultation to restore influence the identified plan, enhance the abilities health; and of others, and effect change. facilitate Standard 5D: Prescriptive Authority and Treatment coping with - The advanced practice registered nurse uses altered prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state EVALUATING To 1. Collaborate with client and federal laws and regulations. : determine and collect data Standard 6. Evaluation Measuring the whether to related to desired - The registered nurse evaluates progress towards degree to continue, outcomes. attainment of outcomes. which modify, or 2. Judge whether goals/outcome terminate goals/outcomes have (Reprinted with permission from American Nurses s have been the plan of been achieved Association. (2004). Nursing: scope and standards of achieved and care. 3. Relate nursing actions practice. Silver Spring, MD: Author.) identifying to client outcomes factors that Make decisions about COMPONENTS OF THE NURSING PROCESS positively or problem status. 1. Assessing negatively 4. Review and modify the - the vital phase of the Nursing Process influence goal care plan as indicated with the following steps: achievement. or terminate nursing 1. Collection of data from different care sources 5. Document 2. Validating the data achievement of 3. Organizing the data outcomes and 4. Categorizing / identifying modification of the patterns in the data care plan. 5. Making initial inferences or impressions 6. Recording or reporting data. Purposes: 1. A way to communicate patient information to other caregivers 2. Method to document initial baseline data 3. Foundation on which to build an effective care plan 4. A way to prove –in court or to a quality assurance committee that you gave quality patient care. Collection: - Data collected should be descriptive, concise, complete and should NOT include interpretative statements. - The nurse records only what is OBSERVED and DOES NOT INTERPRET the client’s behavior. a. Descriptive: - e.g. Situation: Pain is described to be sharp, throbbing on the abdomen. - record what your observed: the client’s lies on his side holding his abdomen. Facial grimacing present throughout assessment. - Do not interrupt: “ The client tolerates Methods of Data Collection pain poorly.” 1. Interview – is a pattern of communication initiated b. Concise: Information is summarized in a short for a specific purpose and focused on a format using correct medical term. specific content area. Purposes in Nursing: Types of data: a. Obtain a nursing health 1. Objective Data - are observations on measurements made History by the data collector. (SIGN) b. Identify health needs - e.g., rash observed 6x4 along posterior thigh. and risk factors c. Determine specific 2. Subjective Data changes in level of - are not directly observable as measurable by persons wellness and pattern of other than the person to whom the data relate. The patient living. will tell another as perceived by himself. (SYMPTOM) Objectives of Nursing interview: - e.g., patient complained of itching at the back of his thigh. a. Initiates nurse-client relationship Sources of Data b. Obtains information 1. Client - best source because it can be the most accurate. from the client in all 2. Family or Significant Others - as primary sources of dimensions. information about infants or children, critically ill, mentally c. Provides the nurse with handicapped, disoriented or unconscious clients. an opportunity to - can also give additional data about the client’s observe the client health status. d. Provides the client with 3. Health Team Members – Consist: Physicians, nurses, an opportunity to obtain allied health professionals and non-professional information. employees working in a health care setting. e. Provides the first step 4. Medical Records – present and past medical records of towards establishing a the patient can verify information. therapeutic relationship 5. Other Records – as educational, military and employment between the nurse and records may contain pertinent health care information. client. Note: Any information about the patient’s medical records In addition, interview is the first step toward is CONFIDENTIAL and is treated as part of the client’s establishing a therapeutic relationship between the nurse legal medical records. and client so health interventions can occur. 6. Literature Review – reviewing nursing and medical literature about the client’s illness helps to complete the 2. Initiating nurse-client relationship database, the review increases the nurse’s knowledge a. Initiate Relationship - Introduce yourself as the about the symptoms, treatment and prognosis of specific interviewer: illness. State your name and position Purpose of the interview b. Communicate trust and confidentiality to the client. - assure the client that the interview is confidential c. Convey professionalism and competence - show professional attitude and manner, appearance. Recording of dates: Record only WHAT is OBSERVED and DOES NOT INTERPRET client’s behavior.  - The interview should be terminated in a friendly Types of Interview Techniques: manner Emergency room - centers on the: 4. Observation - is the basic tool of assessing information Present illness or trauma or behavior with the use of all senses. GENERAL SURVEY Precipitating factors - touch, sight, hearing, taste and smell Medications the client is taking General Survey: Allergies - initially view the patient from the FOOT of the head to allow FACE to FACE contact= the opportunity of Extension Rehabilitation - focus on past and present illnesses and the nurse to make pertinent observations. coping strategies, family and community resources and the client’s - observe patients general appearance present limitation and goals for rehabilitation. - shake hands with him (if allowed) - take VITAL SIGN Approaches in Interview: take note of the following: Directive - used to obtained factual information a. Apparent state of health - SETS of questions are prepared in mind or even - frail, acutely ill, chronically ill WRITTEN form is used (e.g., Nursing HX) b. Signs of distress - DIRECT TO THE POINT - - labored breathing, wheezing, cough for cardiopulmonary Non-directive - usually opens with some general distress discussion and gradually moves to the focus point. This - pain as seen in facial facilitates expression of thoughts and feelings since it is expression, sweating non-threatening and allows the individual to control the - Cold moist pain- anxious flow of discussion. c. Skin color - pallor, cyanosis, jaundice d. Stature and habitus - patients habit Combined Technique - the combination of the two - e.g longer limbs in proportion to approaches which is the most effective. the trunk hypogonadism/marfans syndrome Phases of interview: E. Weight – trusncal fat with relatively thin limbs in 1. Orientation phase - Review the following: crushing syndrome. a. Purpose of interview F. Posture – b. Types of data to be obtained G. Dress grooming and personal hygiene c. Most appropriate method of interview to be used. H. Facial expression – anxiety, depression, pain (5 – 10 minutes is needed to be acquainted with I. Manner, move, relationship to persons and things the client.) around him. 2. Working Phase- as the interview progresses J. Speech – fast by hyperthyroidism - consider TEN STRATEGIES FOR EFFECTIVE K. State of awareness COMMUNICATION: L. VIS 1. Silence - helpful for making observation and M. Any pertinent observation – needled juncture provides the client with time to organize marks thoughts and to present complete information N. Immediate environment – to the interview. 2. Attentive Listening - demonstrates interest in 5. Nursing Health History - obtained during the interview the client needs, concerns, and problems. usually taken in admission that 3. Conserving acceptance- do not be Difference between the NUrsing history and judgemental especially in the clients beliefs Medical History 4. Plan related Questions – the nurse uses Nursing History - deals with the individuals words and word pattern in the client’s normal responses to changes in health statues and socio-cultural context. patterns of living. 5. Paraphrase- rewording ; to validate Medical History - focuses on the sequence of information without changing the meaning of events of the individuals present illness, the clients statements. 6. Clarify - facilitate correct communication 6. Physical Assessment - is taking of Vital SIgns and other 7. Focusing - eliminates vagueness in measurement and the examination of all body parts using communication the techniques of INSPECTION, PALPATION, 8. State observation - provides the client with PERCUSSION AND AUSCULTATION feedback - Conducted after nursing health history 9. Offer information - to clarify treatment, datis gathered. initiate health teaching Approaches: 10. Summarize data gathered- because it will - Cephalo-caudal help validate data and client’s can confirm that - System by system the data are correct. - Need approach 3. Termination Phase - gives a client that the interview is about to end. Four general principles in doing physical examination - by one hand - gain general impression first then focus on specific area - bimanual - Follow planned order of IPPA - graping - The body is symmetrical, compared on one side with the - Ballottement ( other side. - Use all your senses. C. Percussion - act of trapping or striking surfaces of a body part, to learn condition of parts beneath by a resulting Prepare patient for health assessment sound. - explain the procedure - the sound indicate the density of the underlying - measure px height and weight during admission tissue and hus detect the location of body organs attire patient in gown and structure. Place clean paper towel on the scale and ask - Example: patient to remove shoe sor slipper 1. Stomach- Produces a high-pitched, drum- Help patient to stand with his back towards the like sound called TYMPANY because it is scale bar hollow. read height 2. Liver- DULLNESS (low-pitched, thud-like) weight should be taken after the height because it is a dense organ - take vital signs Rule: place the joint on your left middle finger on your - empty the bladder- abdominal organ can be distorted by a patient skin and keep the rest of your fingers up. distended bladder - provide privacy- draping appropriately How to Analyze Percussion Sound: - Provide adequate lighting 1. Intensity – (amplitude) relative loudness or - Proper positioning softness of sound 2. Duration – time period over which sound is heard Techniques of physical exam 3. Pitch – (frequency) caused by vibration of 1. Inspection - is the use of one's senses of vision and smell highness and lowness of a sound to consciously observe the body parts to ascertain quality 4. Quality – (timbre) how one perceives it musically of state of health. 5. Distinct sound produced: Qualities elicited: metal status or level of consciousness state of nutrition and development behavior and emotional reaction abnormal anatomic structure body movement posture and tature color, size, shape, location of any abnormalities odor and sound 2. Palpation - the act of touching a patient in a therapeutic manner by pressure of the hand and fingers to the surface of the body especially to determine conditions of underlying parts or groups. - tenderness D. AUSCULTATION - is the act of active listening to body - temperature organs to information on patients clinical status. - texture TYpes: - vibration 1. Direct or immediate - listening with the unaided ear - pulsation e.g., severe asthmatic attack produces wheezing - masses 2. Indirect or mediate – listening with some Best principle in doing palpation: amplification or mechanical device - stethoscope - short finger nails - to avoid hurting patients and yourself - wash hands prior to touching the patient - old hands can 2. DIAGNOSIS- is the outcome formulated after analysis make the muscles tense distorting findings. (breaking the whole into parts) and synthesis (putting data - Encourage patient to breathe normally throughout together in a new way). - Inform patient WHERE, WHEN AND HOW THE TOUCH According to NANDA 1 - Nursing diagnosis is a click WILL OCCUR ESPECIALLY WHEN THE PATIENT judgment about individual, family response. CANNOT SEE WHAT YOU ARe DOING. Nursing Diagnosis – is a clinical judgement about individual, family, or community Tools in palpation: RESPONSES to actual or potential health - Light palpation - indenting the sin about ½ inches to check problems / life processes. temperature, moisture,and to detect large tumors and Components of Nursing Diagnosis: tender or painful areas. a. Problem - Deep palpation - indenting patient skin more that ½ inches b. Etiology to locate organs and determine their size to detect crepitus c. Signs and tumores, spasticity, rigidity and to feel palpation. MEthods: Types of Nursing Diagnosis: 3. Interdependent Interventions – is completed with or without physician’s order or is written at a nurse’s suggestion. - Client’s problem is solved through a collaborative manner, through judgement with recommendation of the health team. - e.g., referrals; carrying a protocol or standing orders Protocol and Standing Orders a. Protocol – is a written plan specifying the procedure to be followed during an assessment Actual or in providing treatment. Risk Diagnosis (potential problem) - e.g., admitting a patient. Possible Wellness b. Standing Order – is a written Syndrome document containing rules, policies, procedures, regulations, and orders for the conduct of client care in various clinical settings. - e.g., ICU setting c. Specific Drug for irregular rhythm are ordered as a standing order. d. With or without doctor’s order – the nurse will give the medication after assessing such a unique rhythm. B. Decision- Making Strategies for Choosing Nursing Interventions 4. IMPLEMENTING- Execution of nursing plan of care to meet a. Select the interventions designed to achieve goals set with the client. expected outcomes and know the difference Skills Needed: between dependent, independent and a. Psychomotor – Nursing Procedures interdependent interventions. b. Interpersonal – therapeutic command b. Consultation c. Critical thinking – decision about what needs to How? be done. Steps: Process » Identify the general problem area IMPLEMENTATION = a category of nursing behavior in which the » Direct consultation to appropriate actions necessary for achieving the expected outcomes of the professional nursing care plan are initiated and completed. » Provide the consultant pertinent It includes the nursing: information includes: 1. Performing or assisting in the performance of the  Brief summary of the problem client’s activities of daily living. 2. Counselling and teaching the clients or families,  Methods used to resolve the giving care to achieve client-centered goals. problem 3. Supervising and evaluating the work of staff  Outcome of those methods members » Avoid biases by not overloading 4. Recording and exchanging information relevant consultants with subjective and emotional to the client’s continued health care. conclusions about the client and the A. Types of Nursing intervention problem. 1. Dependent Intervention – a nursing action that is » Be available to discuss the findings and completed with a physician’s order that requires recommendation nursing judgement or decision-making.  Provide a private comfortable atmosphere for which the 2. Independent Interventions – can solve the client’s consultant and client can meet problems without consultation or collaboration with the nurse. with physicians or other non-nursing health » Incorporate the consultant’s professionals ; e.g., Medication recommendation into the NCP. C. Implementation Methods 4. Modification – in the NCP. a. Assisting with Activities of Daily Living (ADL) - Modification is based - e.g., eating, dressing, etc. on conclusions. - Conditions resulting in the need for assistance 5. Re-evaluate – continue to with ADL’s can be acute, chronic, temporary, assess plan, implement and permanent or rehabilitative evaluate for as long as you care b. Counselling – help the client use a problem-solving for the patient. process to recognize and manage stress - Emotional, intellectual, spiritual, and B. Benefits of Evaluating - psychological support. - Quality Assurance – an c. Teaching – is closely aligned to counselling. Both using ongoing, systematic, communication skills to effect a change: comprehensive evaluation - In counselling – the change results in the of health care services and development of new attitudes and feelings. the import of those services - In teaching – the focus of change is intellectual on the health care growth of the acquisition of new knowledge or consumer. psychomotor skills - Goal: TO ENSURE Teaching- is used to present correct principles, EXCELLENT HEALTH procedures and techniques of health care. CARE. d. Giving care to achieve the client’s goal - Nursing Interventions Seven Components of Quality Assurance Progress 1. Identification of problem 1. Compensations for Adverse Reactions 2. Setting priorities - Adverse Reaction = is a harmful or unintended 3. Establishment of criteria effect of a medication, diagnostic test, or 4. Selection of assessment methodology therapeutic intervention. 5. Identification of etiology. - How to avoid? 6. Implementation of connective action The nurse must have knowledge about the 7. Evaluation of problem resolution. potential individual effect. e.g., know the side effects of the drug first before taking. During the evaluation process, ask yourself these questions: 2. Preventive Measures 1. Has the patient’s condition improved, deteriorated, - Promotion of the client’s health potential or stayed the same? - Application of prescribed measures as 2. Was the Nursing Diagnosis accurate? immunizations, health teaching, early Diagnosis 3. Have the patient’s nursing needs been met? and treatment and rehabilitation. 4. Did the patient meet the care plan’s outcome criteria?\ 3. Correct Techniques in administering care and 5. Which nursing intervention should I revise or preparing a client for procedures discontinue? - Experience is needed. 6. Why did the patient fail to meet some goals? 7. Should I reorder priorities, revise goals and 4. Lifesaving Measures outcome criteria? - Emergency needs - CPR Nursing Audit – is part of quality assurance - restraining a confused patient. - A thorough investigation designed to identify, - Counselling for a severely anxious client. examine or verify the performance of certain - Experience is needed. specified aspects of nursing care using established - Reporting and Documentation are part of professional standards. implementing (discussion after evaluating Concurrent Nursing Audit – an evaluation of nursing care concept) while the patient is still in the hospital 5. EVALUATION - measures the client’s response to nursing How to Record Evaluation: action progress towards achieving goals, the quality of 1. Continue – the problem still exist and the plan will nursing care provided and the level of nursing care for a continue as is. client. 2. Revised – the problem still exist, but the nursing a. Evaluation Process orders required revision (write the revision) 1. Establishment of outcome criteria 3. Ruled out – a problem that had been designated - e.g., expected outcome: client as possible has been ruled out. able to cough productively 4. Resolved – portion of the Nursing Care Plan( 2. Comparison of client response to NCP) is discontinued. outcome criteria 3. Analysis of variables affecting outcomes and conclusions. - determine the reason for failed plan: REASSESS. OUTCOME EVALUATION Legal Responsibilities of nurses to patients - Planning – Formulation of guidelines what nursing action - Provide quality nursing care utilizing the Nursing to take, to resolve process - nursing diagnoses and develop client’s care plan. Purposes of documentation 1. Planning client care - Each health care professional uses data from the client record to plan for the client. 2. Communication - a vehicle of interaction for all healthcare professionals. This prevents fragmentation, repetition and delays in client care. 3. Legal Documentation - Clients record - is a legal document and is admissible in court as evidence. - Record - is usually considered the property of the agency. 4. Research - information in the record can be a valuable source of data in research. 5. Education - Students in health disciplines often use records as education tools. 6. Quality Assurance Monitoring NURSING PROCESS - the record is used to monitor the care of 1. Assessment the client is receiving and the 2. Nursing Diagnosis competence of the people vining that 3. Planning care. 4. Implementing Nursing audit 5. Evaluating a. Quality assurance monitoring of nursing 6. Documenting b. Peer review DOCUMENTATION 7. Statistics - The best way to protect ourselves is through - statistical information from client records documentation can help an agency anticipate and plan for people's future needs. FLORENCE NIGHTINGALE. - is customarily regarded as the founder of nursing 8. Accrediting and Licensing documentation. She stressed the importance of gathering - Organization as Joint Commission on patients information in a: Accreditation of Healthcare Organization 1. Clear 2. Conscience 9. Reimbursement 3. Organized manner - clinical record must contain the correct DRG (Diagnosis Related-Group) codes and reveal that HEALTH PERSONNEL COMMUNICATE THROUGH the appropriate care has been given and facilitate 1. DISCUSSIONS reimbursement from Medicare or other health 2. REPORTS insurances. 3. RECORDS Types of Records: As her theories accepted, nurses are began to 1. Source Oriented Examples: Important because health personnel communicate through a. Admission Department- admission sheet documentation 1. discussion 2. Problem- Oriented Clinical Records (POR) 2. reports (intershift reports- during endorsement) ▶ The record INTEGRATES all 3. records about a problem whether gathered by  physicians, nurses or others involved in the client’s care. ▶ Coordinates the care given by all health care team members and focuses on the client and the client’s health problems Basic Components of POR a. Baseline Data b. Problem list WHAT’S A PROBLEM? - is a need that the client is unable to meet without assistance from a health professional. - PROBLEM LIST SHOULD INCLUDE: a. Socio-economic b. Demographic c. Physiologic Data d. Psychologic C. Initial list of orders or care plans D. Progress notes 3. Computer Records - Documentation is entered to the computer (installed in the patient’s room) after giving the nursing care. FORMATS FOR NURSING DOCUMENTATION 1. Nursing Care PLans Types: a. Traditional - written for each patient b. Standardized Care Plan Disadvantages of SOAPIE: 2. Critical Pathways 1. Nurses have difficulty determining the most - appropriate place for certain information. 2. Seldom implemented in its pure form because of 3. Kardex modification. - Shortcut - often recorded in PENCIL 3. There is considerable redundancy because there Organized informations: are flow sheets where the same info are found. a. Pertinent informations 4. Not the most efficient method of documentations. b. Medications c. IVF f. FOCUS CHARTING - is a method of d. Tx and procedures identifying patients concerns and e. Diagnostic procedures organizing the narrative documentation to f. Allergies include: DATA, ACTION, RESPONSES g. Specific data on how the client's physical needs for each identified concern. are met, diet, etc. - This was developed by a h. Problem list, goals, and nursing approaches committee of staff nurses at Eitel Hospital in Minneapolis. 4. Progress Notes - Before adopting FOCUS - Methods: charting, the hospital used the a. Narrative Charting SOAP format. The committee b. PIE examined the Nursing Process c. Flowsheets and specific hospital policies and d. Charting by Exception (CBE) collaborated with physicians and e. SOAPIE hospital department heads to - Was introduces in the late 1960’s by Dr. discuss interdisciplinary Lawrenc requirements for documentations. Advantages of SOAPIE: The committee determined the following to be essential 1. Makes it easier to track particular problems for quality information for nursing documentation: assurance monitoring. 1. Nursing Assessment 2. Provides evidence that the plan of care was 2. Nursing Care Plan for each concern implemented. 3. Nursing care provided 4. Evaluation of the patient’s response to intervention Patient’s concerns are identified from data collected during sort the data into the appropriate categories of admission assessment or reassessment during hospitalization. date, action and response 3. Nurses have varying degrees of difficulty The identified concern is not called a problem but a focus that constructing accurate and logical focus notes. eliminates the negative connotation of the word problem. They leave discrepancies between the focus and Patient’s concern or focus is generally phrased as a Nursing the content of the notes. Diagnosis but a focus can also be any of the following: 1. Current behavior or concern – Ex. anxiety, discharge g. patients concerns and organizing the needs narrative documentation to include: 2. A sign of symptom – Fever, nausea DATA, ACTION, RESPONSES for each 3. Acute change in the status – Cardiac arrest, identified concern. seizures - This was developed by a 4. Significant patient care event – chemotherapy, surgery committee of staff nurses at 5. Nursing diagnosis – ineffective breathing pattern R/T Eitel Hospital in Minneapolis. decrease energy. - Before adopting FOCUS charting, the hospital used the The use of foci to identify areas of concern lends together flexibility SOAPformat. The committee to the charting process. The nurse is not limited to identifying only examined the Nursing Process nursing diagnosis or problems. and specific hospital policies and collaborated with physician and hospital department heads to discuss interdisciplinary requirements for documentations. - The committee determined the following to be essential information for nursing documentation.: 1. Nursing Assessment 2. Nursing Care Plan for each concern 3. Nursing care provided 4. Evaluation of the patient response to intervention. GUIDELINES FOR GOOD REPORTING AND RECORDING 1. Accuracy - correct information. FOCUS CHARTING - do not make assumptions when data are 1. D - data not complete. 2. A - action - use precise measurements to ensure 3. R - response / result accuracy. - use correct spelling. Advantages of FOCUS CHARTING - accurate signature includes the 1. Provide structure for the progress notes by organizing the following: content into data, action, response. 1. first name initial 2. Promotes documentation of the Nursing Process. 2. complete surname 3. Increase the ease with which information can be located in 3. status the progress notes. Simply by scanning the focus column e.g. R. Diputado, R.N. the nurse can locate specific information. 4. Nurses are encouraged to identify patient concerns not 2. Conciseness just problems. 3. Thoroughness 5. Promotes analytical thinking by requiring the nurse to Examples of Criteria for Reporting an Recording analyze data and draw conclusions regarding patient’s status. Disadvantages and Problems of Focus Charting 1. If not monitored regularly, the focus charting can become a narrative note with no evidence of patient response to interventions. 2. Focus, like SOAP, requires a change in thinking. The nurse must be able to identify the focus accurately and  a. How to help? i. Keep a dictionary in charting areas ii. Post a list of frequently misspelled words iii. Write a clear and concise sentences 3. Document in blue or black ink and use military time 4. Use authorized abbreviations 5. Make sure the patient’s name is one very sheet 6. Transcribe orders carefully 7. Document complete information about medications: a. time;date b. site of injections c. reasons why meds are omitted 8. Chart promptly 9. Chart after the delivery of nursing care, not before 10. Identify late entries correctly 4. Currentness a. Procedure - Activities that must be communicated at the time they i. Add the entry to the first occur: available in line 1. adm. of meds or other tx ii. label the netry “late entry” to 2. prep. of clients for dx test or surgery indicate it is out of sequence 3. change in a client’s status iii. Record the time and date of 4. admission, transfer, or discharge of a client entry 5. tx initiated for sudden changes in a client’s iv. In the body of entry, record the condition time and date it should had been 5. Organization mate 6. Confidentiality v. 11. Correct mistaken entries PROPERLY a. Procedure: i. Draw a single line through the entry so that is still readable. ii. mistaken entry” – above the or beside the original records. iii. “error” is no longer advisable because juries tend to associate it with a clinical error. iv. Place the date and your initials next to the words “mistaken entry” or M.E. Do’s and Dont’s of Intershift Report 12. Do not tamper with medical records Tampering with cords involves: 1. Adding to the existing record at a late date without indicating the addition is late entry. 2. Placing inaccurate information into the record. 3. Omitting significant tasks. 4. Dating a record to make it appear as if it were written at an earlier time. 5. Rewriting or altering the record. 6. Destroying records. 7. Adding to someone else’s notes. Charting Techniques 13. Chart only care you provided or supervised. 1. Write neatly and legibly 14. Avoid using the medical record to criticize other health 2. Use proper spelling and grammar care professionals. 15. Fill in the blanks on chart forms. 16. Document any comments the patient makes about a potential lawsuit against a health care provider o institution. 17. Eliminate bias from written description of the patient. 18. Be precise in documenting the information you report to the physician. Document potentially contributing patient acts. a. A patient’s referral or inability to provide accurate and complete info. b. Non-compliance with medical and nursing care. - staying in bed - dietary restrictions - return appointment - leaving against medical advice - abuse or refusal of medical intervention c. Presence of unauthorized personal items at the bedside. d. Tampering with medical equipment. IN THE EVENT OF A “LAWSUIT”, THE MEDICAL R E C O R D M A Y F O R M T H E B A S I S , F O R T H E PLAINTIFF’S CASE OR THE NURSE’S DEFENSE. THE PATIENT’S CHART HAS BECOME THE DETERMINING FACTOR IN 80-85% IN ALL MAL- PRACTICE LAWSUITS INVOLVING PATIENT CARE. SOME ATTORNEYS BELIEVE THAT NURSE’S PROGRESS NOTES ARE THE MOST FRUITFUL SOURCE OF PROOFS OF SIGNIFICANT EVENTS. AS TIME PASSES, MEMORIES DIM AND CONFLICTING ARGUMENTS ARE VOICED, JURIES TEND TO BELIEVE THE RECORDS.