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Chapter 33-37 Study GuideA primary goal of nursing is to help individuals meet their basic and higher-level needsMeeting with clients lead to specific interactions, including communication, observation, support, education, and provision of careNurses provide care to clients by combining scientific problem-solving methods with critical thinking skills to provide care through the nursing processProblem-solving Is the basic skill of identifying a problem and taking steps to resolve mon sense is helpful in solving many problemsTrial and error problem solving is an experimental approach that tests ideas to decide which methods work and which do not. Trial and error must be used carefully when working with people because of the possible harmful resultsScientific Problem Solving:Scientific problem solving is a precise method to investigate problems and arrive at solutionsThe 7 steps of scientific problem solving:Identify the problemGather information relative to the problemFormulate tentative solutions (hypotheses); choose preferred solutionPlan action to test suggested solutionExperiment and observe the resultsInterpret the results (draw conclusions); understand what the results meanEvaluate the solution, either concluding or revising the study to test the solution again if results are unsatisfactoryScientific problem solving requires both logical thought and imagination Critical Thinking:A complicated mix of inquiry, knowledge, intuition, logic, experience, and common sense is called critical thinkingCritical thinking enables you to grasp the meaning of multiple clues and to find quick answers when facing difficult problemsCritical thinking is neither trial and error nor a structured scientific problem-solving system Concept Mastery Alert: Critical thinking helps the nurse grasp the importance of multiple clues in the client’s situation. For example, a client is admitted to the healthcare facility with breathing difficulty. The nurse observes that the client has had a productive cough with thick, purulent sputum several times in the past hour. The nurse takes into account the presence of multiple clues, judges them to be of a serious nature, and decides to notify the physician.As a critical thinker, you form your own beliefs or ideas rather than automatically accepting the thoughts or ideas of others. You become an open-minded person, flexible to alternativesYou also use your imagination and creativity systematically to gather information and draw conclusionsWhen you think critically you can grasp the nature and extent of problems more quickly and easilyThe framework for thinking and acting is called the nursing processThe process is a special way of thinking about how to care for clients.The process Is also described as a systematic method that directs the nurse and client as they together (1) determine the need for nursing (2) plan and implement care (3) evaluate the resultsThe nursing process is a method you use to identify and to treat client care problems.Traditionally these guidelines are developed into a format referred to as a nursing care plan (NCP)Clinical nursing units may use other terms in lieu of nursing care plans, such as critical pathways, concept mapping, or clinical pathways, but the process of thinking through the nursing process remains basically unchanged whatever phrase is usedThe nursing process framework enables you to develop plans of care individualized for each client, identifying what is suitable and desirable for that particular personThe care plan helps you manage your time more effectively as you provide careBecause the nursing care plan is available for other nurses to use as well, it provides consistency and focus in carePotential needs or potential problems are those problems that might be prevented or problems that the client is at risk for developing. The effective use of the nursing process allows you to identify not only actual problems but also situations that may be avoidedPrevention of problems, complications, or impediments to care requires excellent nursing observations and interventions. Biological hurdles caused by a disease process or by hindrances to healing are commonThe ability to foresee problems may avert painful, as well as costly, complicationsNursing Alert: It is also important to understand that individual states and clinical facilities will provide regulations, rules, and guidelines that are unique for the LPN/LVN and the RN. Each State’s Nursing Board may define the roles of LPN/LVNs and RNs differently, especially when discussing the initiation and utilization of the nursing process. You will need to know the Nurse Practice Act and the local regulations for your location and situation.Steps in the Nursing Process:Nursing Assessment: the systematic and continuous collection of dataNursing Diagnosis: the statement (or label) of the client’s actual or potential problemsPlanning: the development of goals for care and possible activities to meet them Implementation: the giving of actual nursing careEvaluation: the measurement of the effectiveness of nursing careCharacteristics of the Nursing Process:Systematic: the nurse follows specific, orderly, and logical steps based on the client’s most important and often most vital needs, also known as prioritization or prioritizingClient-Oriented: The needs of the client are identified, not the needs of the nurse, family, or other healthcare providersYou, as the nurse, focus on meeting individualized client needs, rather than on performing specific skillsThe nurse aide or the UAP may know the skill of taking vital signs, but is not responsible for knowing why specific actions are doneGoal Oriented: Goals, objectives, or expected outcomes are established as an early part of the nursing processGoals can be short term or long term and are ranked according to the client’s priority needs and preferences.Short-term goals are measurable outcomes that can be achieved in hours, days, or weeks, depending on individual problemLong-term goals take the short-term goals into consideration, but also provide guidance for the days, weeks, or months during and after the time a client is seen by a healthcare providerContinuous: Because the life and health of individuals change, reassessment of the client’s needs is done frequently, sometimes, hourly (or more frequently in critical care settings). The existing nursing process at times must be redesigned spontaneously to fit the most current and highest priority needsThe nurse must continuously reassess, make new goals, implement new plans, insert new interventions, and re-evaluate success of the overall process.A nursing care plan is revised as new needs are identified, changes in status occur, or when it is recognized that the current NPC has not been successful.Dynamic: Although it contains definite steps, these steps often overlap, sometimes they all occur at onceAs you develop nursing care plans, you gain comprehension of these characteristics of the nursing processNursing care plans often reflect your growth in comprehension of the client’s needs. Communication and Quality Care: As the method or tool for disseminating measurable and observable evidence, the nursing process indicated the effectiveness, or quality, of nursing care.The quality of care can be documented as a goal that is completed, as written in the original care plan, or as a new goal, that is rewritten as a result of evaluation of goalsDue to the individual nature of healthcare, it is not possible for all proposed goals to be successful. The evaluation component of the care plan should be the source of the communication of the success of a goal or the need for a new goal.A quality care plan also may suggest that the features, interventions, or goals of the original plan need changesChapter 34:Nursing Assessment:The nursing process begins as soon as you enter a nurse-client relationship. Nursing assessment is the systematic and continuous collection and analysis of information about a client.The assessment begins with collecting data and putting the data into an organized format. During the data-collection assessment phase, the nurse begins to perceive and identify existing problems or needsExisting needs are often priority over potential needs, which are often listed as at risk forData Collection:The best sources of information about the client are the client and familyCongruence occurs when two or more sources of data are compatible or consistent, having the same or very similar descriptions. Key Concept: Many sources provide the healthcare team with information. In spite of the source, HIPPA’s confidentiality regulation mandate that information about the client can be shared only with the client. The healthcare team is allowed to review data but is not approved to share this information with family or caretakers unless the client specifically designates the others as acceptable recipients of the information. Data about a client falls into one of two categories: Objective and Subjective Objective data includes all the measurable and observable pieces of information about the client and his or her overall state of health.The term objective means that only precise, accurate measurements or quantifiable descriptions are usedJudgement, opinions, or client statements are not considered objective dataConcept Mastery: Objective data are measureable and observable. Objective data do not include the nurse’s interpretation of observed data or a client’s statement of symptomsSubjective Data consist of the client’s opinions or feelings about what is happeningSometimes the client communicates through body language: gestures, facial expressions, and body postureBoth spoken and written words and body language tell you the client’s opinions and feelings. To obtain subjective data, you need sharp interviewing, listening, and observing skillsAlways be sure to consider cultural factors, such as specific body postures and use of eye contact, the client’s beliefs about health and illness, or the use of special amulets or folk remediesKey Concept: Objective data are obtained from the objects that measure or quantify information. Subjective data are gained from the client’s, that is, the subject’s verbal or nonverbal point of view such as feelings, expressions, or sensations of painMethods of Data Collection:Methods used to collect data include observation, interview, laboratory and other diagnostic tests, and the physical examination.When analyzing data, a holistic picture emerges that may include physical, psychological, and socioeconomic problems, concerns, and needsThe nurse individualizes the data, prioritizes the information, and shares this information with other team members. Observation is an assessment tool that relies on the use of five senses (sight, touch, hearing, smell, and taste) to discover information about the clientThis information relates to characteristics of the client’s appearance, functioning, primary relationships, and environmentVisual Observation: the sight provides an abundance of clues that must continually process when assessing the clientExamples of visual observation: body movements, general appearance, mannerisms, facial expressions, mode of dress, nonverbal communication, interaction with others, use of space, skin color, and appearance, and cleanliness.You also use visual observation when you inspect the client’s skin for rashes or irritation and note the cleanliness and level of safety of the client’s immediate environmentTactile Observation: the sense of touch provides valuable information about the clientTouch or palpation of the skin assesses factors such as muscle strength, temperature, moisture, edema, rash, or swellingAuditory Observation: Hearing allows you to listen actively to the client and family as they interact with you and other members of the healthcare teamOlfactory or Gustatory Observation: the sense of smell identifies odors that can be specific to a client’s condition or state of health.Some microorganisms’ infections have specific, identifiable odorsOlfactory observations include noting body and breath odors, which might indicate alcohol intoxication, poor hygiene, or metabolic acidosisIt should be noted that a client who lacks a sense of smell often is anorexic (lacks an appetite) because smell stimulates specific taste sensationsSpecial Considerations: When making observations, be sure that you consider cultural and ethnic factors or practices that may influence your findingsThe health interview is a way of soliciting information from the client. The interview may also be called a nursing history If the interview is conducted when a client is admitted to a healthcare facility, it may be called an admission interview. The nurses progress notes are commonly referred to as the nurses’ notesDuring the health interview, you may guide the conversation with direct questions or the client may direct dialogue by discussing health problems, symptoms, or feelings about his or her needs. When gathering information, all methods of communication should be usedData collection and assessment are combinations of open-ended questions, detailed questions (often close-ended questions), plus observational and tactile skills.It is also important to consider factors, such as the client’s level of pain, comfort, exhaustion, or physical situation.Even when the client can respond, family members may give you additional informationA complete health history helps you develop an effective plan of care for the clientComponents of Nursing History:Biographical Data: includes name, age, birth date, spouse, support person, children, address, phone number, occupation, financial status, insurance, and so forthReason for coming to the healthcare facility: Addresses the primary reason, also described as the client’s chief complaint (CC) or perception of illness. What does the client expect to happen in the healthcare facility?Recent health history: Includes symptoms of recent disease treated with medications and/or surgery, and exposure to communicable diseases.Important medical history: Includes family history of disease, allergies, immunizations, medications, and use of alternative/complimentary therapies and herbal supplementsPertinent psychological information: Addresses family relationships, employment, living conditions, emotional stability, sexual relationships, substance use or abuse, medications, or so forthActivities of daily living (ADL): Involves how well the client is able to meet basic needs, such as eating, drinking, bathing, dressing, and toileting. Does the client get adequate exercise, food, rest, and sleep?Key Concept: You will use the following methods to collect data:Observation (use of five senses)Interview (the nursing history)Physical examination (general survey and specific examinations)Data Analysis:During and after data collection, you must critically examine each piece of information to determine its relevance to the client’s health problems and its relationship to other pieces of informationThrough systematic data analysis, you can draw conclusion about the client’s health problems. Information itself may pose difficulty when interpreting dataYou may find that you have too much information or not enough informationWhen preparing to analyze data, ask yourself which items are pertinent to client care and which are notRemember: The correct first response typically is not to “notify the physician” but rather perform a bedside nursing action, such as apply oxygen, and then to notify the appropriate nursing supervisor and/or healthcare providerOne way to validate observation is to “check them out” with the clientDo your observations agree with what the client is experiencing or are they only your interpretation?Sometimes, thinking of clients as “team leaders” who are directing the members of the healthcare team is helpful.Some data are similar or have a pattern or connection and are identified as symptomsPatterns may occur at a particular time of day or night, after eating, after walking, or when the client is in a certain positionThese symptoms can be grouped together in clusters for further analysisRecognizing data clusters helps you determine relevant informationKey Concept: Nurses must be able to connect basic laboratory results with client symptoms. For example, a decreased red blood cell count may present the symptom of shortness of breath. Another common example occurs when the client has an elevated white blood cell count, which may be reflected as a client’s elevated temperature and rapid pulse. While assessing the client, look for strengths the client has that he or she can use in coping with problems. Through careful analysis of data clusters, you may identify actual or potential problemsReaching Conclusions:Four conclusions are possible:The client has no problemThe client may have a problemThe client is at risk for a problemThe client has a clinical problemThe problem is a nursing diagnosis if it falls in the domain of nursing, and nursing staff may treat it without consulting a physicianIf the problem requires medical treatment (medical diagnosis), you have identified a collaborative problem. When this occurs, you must consult a physician and work together to resolve the problemKey Concept: The nursing assessment is the systematic and continuous collection of data about a client. It includes the following steps:Identifying assessment priorities related to the purpose of the interviewCollecting data about the client form observation, interview, and physical examinationContinuously updating the database of informationRecognizing significant dataValidating observationsRecognizing patterns or clustersIdentifying strengths and problemsAnalyzing data to reach conclusionsChapter 35The first step of the nursing process is data collection which is the collection of objective and subjective information for the nursing assessment The second step of the nursing process is identifying the nursing care problem, otherwise called the nursing diagnosis based on your analysis of the dataThe third step of the nursing process, which is planning client care based on the problems or diagnoses you have identified A nursing diagnoses is a statement about the actual or potential health concerns of the client that can be managed through independent nursing interventionsNursing diagnoses are concise, clear, client-oriented, and client-specific statementsKeep in mind that a nursing diagnosis is an approved label that identifies the client’s problems in nursing terminology Concept Mastery Alert: Assessment is analyzing data that has been collected in order to arrive at the nursing diagnosis. The nursing diagnosis is a statement about actual or potential problemsThe words, phrases, and/or terms of NANDA-I’s nursing diagnoses are actually the diagnostic labels or categories on which an evidence-based, client-oriented nursing diagnosis statement is built.The nursing process uses these nursing diagnoses as part of the fundamental steps involved in the concepts of critical thinking Medicine emphasizes the disease process or the etiology of the disorder.A medical diagnosis is obtained from a list of accepted medical problems compiled in a major database known as the International Statistical Classification of Diseases and Related Health Problems. It is more commonly known as the International Classification of Diseases, shortened to ICD-10.The medical diagnoses are listed by body system, such as diseases of the nervous system, or by general commonalities, such as injury and poisoningRemember these facts about a medical diagnosis:A medical diagnosis identifies the disease a person has or is believed to havePhysicians arrive at a medical diagnosis by studying the physiologic manifestations of the illness and establishing its cause and natureA medical diagnosis provides a basis for prognosis (projected client outcome) and medical treatment decisionsNursing diagnoses focus on the client, the individual’s physical and psychological responses to an existing or potential conditionNursing diagnoses look at the nursing observations and actions and how nursing care can affect the needs of the client, such as an individual’s ability to function, to cope with specific problems, or to learn how to care for a problem (self-care)Remember these general concepts relating to the nursing diagnosis:A nursing diagnosis is based on nursing observations and data collectionA nursing diagnosis suggests nursing actions or nursing interventionsA nursing diagnosis recognizes the client’s ability for self-care, to cope with specific problems, or to respond to existing or potential conditionsPurposes of the Nursing Diagnosis:Identifying nursing priorities Directing nursing interventions to meet the client’s high priority needsDirecting nursing interventions to meet the client’s short term and long-term goalsDirecting nursing interventions to meet the client’s needs for discharge planning, educational needs, or post-discharge follow-upCommunicating in a common languageIntegrating actions and goals between the nursing professionals and the healthcare teamForming a process to evaluate the benefits of nursing careProviding assistance when determining the client’s acuity level or the client’s needs for nursing careDuring the assessment/data collection component of the nursing process, it is likely that the client will present with more than one problem.The nursing care plan may be made up of multiple diagnostic statementsEach diagnostic statement has two or three partsThe 3part nursing diagnostic statement consists of the following components:Problem: General label (e.g. airway clearance, ineffectiveEtiology: Specific, related factors such as excessive mucus or foreign-body obstruction. Note that the etiology is obtained from a nursing observation (excessive mucus)Signs and Symptoms: Specific, defining characteristics (signs or symptoms) written in the following format: as evidenced by (AEB) or as manifested by objective or subjective data such as the shortness of breath on exertion. Note that the signs and symptoms are specific events or issues that have developed from the basic etiologyThe problem portion of a statement describes clearly and concisely a health problem a client is havingKey Concept: Writing nursing care plans is a process that continually evolves. It is important that the contemporary nurse document according to his or her licensure limitations and within the guidelines of the employing institution.The etiology part of the diagnostic statement is the cause of the problemEtiology may be physiologic, pathophysiologic, physiological, sociologic, spiritual, or environmental Data collected during the nursing assessment delineates the nursing diagnosisA nursing diagnosis has three components:P-Problem (diagnostic label)E- Etiology (cause)S- Signs and symptoms (the objective and subjective information observed and documented)The diagnostic statement connects problem, etiology, and signs and symptomsThe first parts of the statement are linked by related to, sometimes abbreviated R/T The last two parts are linked by as evidenced by, sometimes abbreviated AEBWhen formulating a nursing diagnosis, make sure that it is something staff and client can treat without orders from the physician, such actions are called independent nursing actionsIf treatment requires something you cannot do, such as prescribe medication for the cough, the problem is a collaborative problemA collaborative problem means that you will work together with the physician or other healthcare providersKey Concept: The nursing diagnosis is a statement about the client’s actual or potential health concerns that can be managed through independent nursing interventions. It contains the following steps:Establishing significant dataWriting a two-or three-part diagnostic statementPlanning Care:After identifying the nursing diagnoses, you begin planning nursing carePlanning is the development of goas to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goalsSetting priorities, establishing expected outcomes, and selecting nursing interventions result in a plan of nursing careSetting Priorities: The assessment or data collection component of the nursing process reveals situation that are concerned with immediate or critical needs, these are called the priority needsThe most important, that is, priority needs must be identified and addressed firstOn the nursing care plan, nursing diagnoses are prioritized; that is, nursing diagnoses, goals, and actions must be listed in order of importanceSurvival needs or imminent life- threatening problems take the highest priority Safety needs are the next priority with nursing diagnostic categories such as risk forThe medical diagnosis may be the legal reason for admission to your facility, however, the medical diagnosis may not be the priority nursing concern at any given momentNursing care will involve relief of pain, prevention of complications due to immobility, or psychosocial concernsEven though some problems can be deferred until a later time, the nurse must simultaneously keep in mind that care needed for future problemsEstablishing Expected Outcomes: An expected outcome is a measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care, it may also be called a goal or objectiveAn expected outcome has the following characteristics:Client-oriented: The client, not the nurse, is expected meet this outcomeSpecific: Everyone, including the client, knows what is to occurReasonable: The outcome should be within the client’s capacity and abilities, considering the confines of his or her conditionMeasurable: The behavior can be observed and measured Working together you and the client should determine outcomesExpect clients to achieve outcomes in varying lengths of timeA short-term objective is an expected outcome or goal that a client can reasonably meet in a matter of hours or a few daysA long-term objective is an outcome that the client ultimately hopes to achieve, but which requires a longer period of time to accomplishKey Concept: Expected outcomes are client oriented, specific, reasonable, and measurableSelecting nursing Interventions:Nursing interventions, also called nursing orders or nursing actions, are nursing activities that will most likely produce the desired outcomes (short term or long term). Sometimes, the client and nursing staff set specific target dates for achieving certain goals, checking them off as they are completedNursing orders may include such things as further assessment, client teaching, or referralSpecific nursing interventions are selected because scientific research has demonstrated that these actions are effectiveWriting a Nursing Care Plan:The nursing care plan is the formal guideline for directing the nursing staff to provide client care.Ideally, the nursing team formulates the nursing care plan at a meeting called a nursing conference or team conference, sometimes one or two nurses may create the care planThe initial care plans are written to provide instructions and guidelines for the total healthcare team to use for direction and communicationThe nursing care plan usually includes nursing diagnoses or client problems (according to priorities), expected outcomes (short- and long -term objectives or goals) and nursing orders (activities nurses carry out to help the client achieve goals). The care plan is an everchanging guide, which is updated regularly as the client’s condition changesRegardless of the manner in which the care plan is developed, it becomes part of the client’s permanent health recordThe ideal nursing care plan is individualized for each clientStandardized care plans allow for additions or substitutions so that the care plan can be individualized to the specific client. Key Concept: Planning is the development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals. Remember the following steps involved in planning:Setting prioritiesEstablishing expected outcomesSelecting nursing interventionsWriting a nursing care planChapter 36Implementation of a nursing care plan may be also referred to as providing nursing interventions or nursing actionsImplementing Nursing Care:“Do it,” “share it” and “write it down” are the actions phrases of implementation.You “do” nursing care with and for the clientYou “share” the results by communicating with the client and other members of the healthcare team, individually or in a planning conferenceYou “write” information by documenting it so that the next healthcare provider can act with purpose and understanding Always remember that adequate communication and documentation facilitate the continuity of careWhen implementing care, you will do things, or as nursing prefers to say, intervene on behalf of the clientsThe nursing actions that are done may be dependent, interdependent, or independentDependent actions are based on the orders or specific directions from the healthcare provider, such as providing medication or treatmentsInterdependent actions are those that you perform collaboratively with other care providers; the healthcare provider may write orders for some of these actionsIndependent actions are nursing actions that do not require a healthcare provider’s orders.Only you as a member of the nursing staff perform independent nursing actions, which are based on your judgementKey Concept: Nursing actions involve the use of common sense and critical thinking. In everyday practice, you need to obtain pertinent information such as VS before calling the healthcare providerIntellectual skills involve knowing and understanding essential information before caring for clientsInterpersonal skills involve believing, behaving, and relating to othersSolid communication techniques and client encounters that promote the development of a trusting relationship (rapport) are interpersonal skillsBehaving professionally also involves interpersonal skillsTechnical skills involve the ability to manually perform a taskThe nursing team determines if the plan, as written, makes senseAs you care for clients, observe them carefully. Listen to what clients say; watch what they do; check their VSUse critical thinking continually to determine if the nursing orders are effective in moving clients toward meeting their specified goalsPeriodically, a client planning conference is held in which information about the client is shared among the various members of the healthcare teamInterdisciplinary planning conferences offer an excellent way to coordinate your nursing care and to interact with other health disciplines You will document all care given to a clientDocumentation whether written by hand or by computer, is an extremely important aspect of accountability and responsibility of nursing careConsider the phrase: If it is not written, it was not doneKey Concept: Nursing implementation means the carrying out of the nursing care plan. It includes the following steps:Putting the nursing care plan into actionContinuing the collection of dataCommunicating care with the healthcare teamDocumenting careEvaluating in measuring the effectiveness of assessing, diagnosing, planning, and implementingSteps in the evaluation of the nursing care are: analyzing the client’s responses, identifying factors contributing to success or failure, and planning for future careSeveral means to evaluate the effectiveness of nursing care:Client: The primary source of evaluation criteria Is the client. The family may also be helpful in determining if care given was effectiveTeam conference: A conference is helpful not only to plan nursing care, but also to evaluate the effectiveness of care and design a discharge planCommunity health agencies: Another way of evaluating outcomes of care is to contact healthcare providers in community agencies who are in touch with clients after they leave your facility. Such providers include public health nurses, school health nurses, social workers, and receptionists and nurses who work in healthcare provider’s officesThe established goals and objectives of the nursing care plan become the standards or criterial by which to measure the client’s progressThe evaluation process is not intended as a positive or negative response to a nursing care.Evaluations are based on the client’s overall responses to nursing care, medical interventions, and physiologic reactionsDuring the evaluation phrase of the nursing process, the nurse needs to be objective when reviewing data, focus observations on factors related to goals, and combine common sense with critical thinking skills in order that new goals match the client’s conditionRemember: you are responsible for ensuring that your knowledge and skills are always of the highest quality The nursing process is dynamic and cyclical. Resolved problems are noted on the care plan or care path as “resolved”If goals remain unmet, you must consider the reasons these goals are not being achieved and suggest revisions to the nursing care plan Key Concept: Nursing evaluation is the measurement of the effectiveness of assessing, diagnosing, planning, and implementing. Evaluation includes the following steps:Analyzing the client’s responseIdentifying factors that contributed to the success or failure of the care planPlanning for future nursing careDischarge planning is the process by which the client is prepared for continued care outside the healthcare facility or for independent living at homePreparing for discharge begins when a client is admitted to the healthcare system and is ongoing throughout the client’s plan of careBecause clients achieve different levels of care at different times, the discharge plan must be individualizedThe purpose of a discharge conference is to identify long-term goals that are still unresolved and to plan for continued assistance to the client. The primary nurse, or team leader, is responsible for seeing that the client, family or caregivers have the necessary discharge instruction. Key Concept: Discharge teaching begins on admission and continues throughout the client’s care. The client and family cannot be expected to remember a large amount of teaching at one time, especially just as the client is leaving the facility. Discharge planning may include written instruction, skills demonstration, and/or verbal teaching. The client, the family, and or more significant persons may be included in the discharge planningReview box 36-1 on page 433Chapter 37The health record is a manual (handwritten) or electronic (computer) account of a client’s relationship with a healthcare facilityHealthcare providers chronologically and systematically record all information regarding the client’s health, past and current problems, diagnostic tests, treatments, responses to treatments, and discharge planning through handwritten or keyboard entriesThe commonly used term for documenting is “charting”Accurate and complete documentation in the client’s health record is an essential communication tool. It is used:To maintain effective communication among all caregiversTo provide written evidence of accountability To meet legal, regulatory, and financial requirementsTo provide data for research and educational purposesBecause the goal of the healthcare team is to work together to provide the best possible care for the client, the health record is a communication tool that all caregivers use to exchange information about the client’s condition, treatments, responses to treatments and plansThink of the health record as a bank where information is deposited, stored, and made available to all who need itThis central resource for information ensures that a client’s care is consistent and effectiveAnother aspect of communication that is important to the client is the documentation and verification of his or her own health statusKey Concept: When communicating with others, it is important to consider each person’s age, sex, ethnic and religious background, state of health, life experiences, body image, feelings about being in the healthcare facility, language preference, and other personal factorsAccountability means responsibility for actionsThe health record is documented evidence that the healthcare agency and providers have acted responsibly and effectivelySuch evidence of accountability is required for legal, regulatory, and financial reasonsAccountability for documentation, as well as initiation of appropriate actions, is a component of the nursing process and nursing regulationsThe Joint Commission, in conjunction with Centers for Medicare and Medicaid Services (CMS) has developed core measures that provide standards of careReclassified as accountability measures, their goals are to delineate criteria that produce the greatest positive impact on the outcomes of client careReview Box 37-1 on page 436Major issues involved with compliance and accountability:The health record is an important piece of evidence when questions of inadequate, incorrect, or poor healthcare arise. Accurate, precise, and timely entries into the health records are your protection against accusations of inadequate of poor nursing careNCLEX Alert: If your health records are audited or if you go to the court, the basic legal concept is: If it was not documented, it was not doneReview major issues for compliance and accountability on page 436- too much to typeThe health record is either a manual (paper) document, an electronic document, or a combination of bothElectronic documents are located in a medical information system (MIS), which is housed in a computer networkThe MIS may contain only specific medical informationAnother documentation system is referred to as electronic medical records (EMRs)The manual health record is a collection of various forms and documents. Some forms may be kept at a client’s bedside for your practical convenience for example, a fluid intake and output sheet or a flow sheet. The nurse is held legally responsible for the legibility, thoroughness, and timeless of documentation. Sophistication of computer software has evolved to enable the bedside practitioners to store, process, and transmit client dataKey Concept: If the healthcare facility where you work uses an electronic system, you will need to take orientation classes to learn how to use the system correctly. NEVER share your access code(s) to a facilities electronic documentation system. The health record contains 4 general categories of information: assessment documents, plans for care and treatment, progress records, and plans for continuity of care Key Concept: Confidentiality is a major concern. It is imperative that a client’s healthcare information be protected. Never share electronic information unless documentation protocols provide for the transmitting of data from one person or place to another person or place. Assessment Documents:Assessment documents record all information about the client obtained through interview, examination, diagnostic procedures, or consultation. These documents include the healthcare provider’s history and physical examination, the nursing admission history, and other records that list or describe related aspects of information about the client.All caregivers contribute to this bank of informationPlans for Care and Treatment:The purpose of the plans for care is to ensure that all caregivers provide cohesive, coordinated care, and treatments for the client. The healthcare provider’s plan of care contains goals for treating the client and specific instructions called orders to guide the nursing staffSome nurse practice acts require that the nursing care plan be developed by the registered nurse after a thorough assessment of the client’s health statusThe needs of the client, the facility, and the nurse commonly dictate which format will be chosen for plan of care documentationFormats of Documentation:Many formats for charting or documenting the client’s progress exist. Charting is based on the nursing process: assessment, nursing diagnosis, planning and goal setting, implementation/interventions, and evaluationReasons to use a progress note entry are:Establish a baseline of dataDocument the accountability (core) measures of admissionEnter data at regular intervalsSummarize the client’s conditionDocument changes in the client’s conditionDocument a response to treatmentTypical documentation formats include:Narrative-chronologicalProblem-oriented (focus)Discipline area documentationCharting by exceptionSystem flow sheetCase ManagementCritical pathwayCollaborative pathwayCare mappingGraphic flow sheetMedication administration recordNarrative-Chronological: Progress notes are written in several formats, often using specific forms, which usually are designed by each institution. A progress note essentially summarizes the progress of the client toward achieving his or her care plan goals. A progress note can be a summary or narration of an event, conversation, assessment, or activity. This narrative format is kept chronologically. Charting can be done hourly, every 2 hours, per event, or more oftenWhen nurses chart on a progress note, the form is commonly called the nurses’ notes. Key Concept: In some areas, “reporting by exception” is practiced. In this case, not all recurring client information is repeated. The nurse only reports changes in the client’s condition, new orders, upcoming procedures, and unusual or changing behavior.Read all documentation formats on pages 439-442Information that is kept on a graphic flow sheet include:Vital signsIntake and outputADLsDietary or eating patternsNeurologic checks (“neuro checks”)Restraint observation and documentationFrequent blood sugar monitoringPostoperative recordsWound care and monitoringPlans for Continuity of Care:During admission, transfer, or discharge from the agency, healthcare personnel use specific forms to ensure that the client’s care is continuous, consistent, and effectiveTeaching plans, transfer notes, and discharge summaries contain information that enables other caregivers to ensure continuity of careGuidelines for Documentation:The quality of documentation says much about the kind of care you giveAccurate and complete documentation is important for effective communication and accountabilityDocument exactly what you observe, and document what you see.Describe your assessments objectively; do not give your opinions or interpretationsBe specific, avoid ambiguous statements and generalization, avoid judgmental words such as well, fair, poor, or goodUse Direct Quotes, directly quote the client, and differentiate the client’s words from your observation. Enclose the client’s statement in quotation marks so others will know exactly what the client saidBe prompt, document immediately after giving all care, medications, and treatmentsThe health record does not have memory relapses, although you may If you forget to document a pertinent fact and add it after you have entered other documentation in the health record, you must identify your entry as a “late entry”Be Clear and Consistent, correct spelling, punctuation, and sentence structure are essential On manual record, write or print neatly in black inkMake sure the record is continuous and legible Always indicated the date and the time of entry Be aware that most facilities use the 24 -hour clock To decrease the chances of misreading or misinterpreting, prevent medication errors, and promote safety for the client, the Joint Commission has complied a “do not use” listSign the chart with your first initial or full first name and full last name and classification Do not leave vacant lines in the health record, using every line maintains the chronology of charting. Always return the health record where it belongs, never remove it from the nursing station unless you have consulted the charge nurse or team leaderReview Box 37-2 and Box 37-3 on page 443, Box 37-4 on page 444 and boxes on page 445Document all communications with other members of the healthcare teamRespect Confidentiality:Confidentiality means that conversations with clients and nursing observations and assessments are shared only with the appropriate caregivers in the proper settingErasures and the use of correction fluid on a client’s manually written health record are illegalSuch measures can be considered an attempt to hide poor nursing care or an error made in client careIf you make an error in documenting; cross out the incorrect statement with a single line, enclose it in parentheses, and write ERROR and you initials next to itYour original note must be readableSome agencies recommend using recorded in error (RIE)Key Concept: The importance of careful documentation in healthcare cannot be overstated. You must make sure to document all nursing assessments and actions completely and accurately.Several times during the day the nurse must “report off” to another nurseChange-of-shift reporting is a means of exchanging information between the outgoing and incoming staff on each shiftThe team leader may report to the entire incoming shift, or reports may be given from care giver to care giverIn walking rounds, caregivers move from client to client, discussing pertinent information.Walking rounds encourages client participation and enables the oncoming staff to view equipment, dressings, and other treatments with the previous nurseThe outgoing nurse introduces the incoming nurse to the client. This technique personalizes client care and helps establish rapport.Key Concept: This change of shift report may be given in person, in writing, or by tape recorder. If the report is verbal, make sure it is given in a location where clients or visitor cannot overhear you. ................
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