NURSING AS A SCIENCE 5

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Cards (54)

  • IMPLEMENTING AND EVALUATING
     
    • the action phase in which the nurse performs the nursing interventions
    • consists of doing and documenting the activities that are specific nursing actions needed to carry out the interventions.
  • SKILLS:
     
    1. COGNITIVE SKILLS
    2. INTERPERSONAL SKILLS
    3. TECHNICAL SKILLS
  • INTERPERSONAL SKILLS –are all of the activities, verbal and nonverbal, people use when interacting directly with one another
  • TECHNICAL SKILLS – are purposeful (hands-on) skills such as manipulating equipment, giving injections, bandaging, and repositioning client.
  • COGNITIVE SKILLS – problem solving, decision making, critical thinking, clinical reasoning and creativity
  • PROCESS OF IMPLEMENTING
     
    1. Reassessing the client
    2. Determining the nurse’s need for assistance
    3. Implementing the nursing interventions
    4. Supervising the delegated care
    5. Documenting the nursing activities
  • GUIDELINES FOR IMPLEMENTING NURSING INTERVENTIONS
     
    1. Base nursing interventions on scientific knowledge, nursing research, and professional standards of care (evidence-based practice) when these exist.
    2. Clearly understand the interventions to be implemented and question any that are not understood.
    3. Adapt activities to the individual client.
    4. Implement safe care.
    5. Provide teaching, support and comfort.
    6. Be holistic.
    7. Respect the dignity of the client and enhance the client’s self-esteem
    8. Encourage clients to participate actively in implementing the nursing interventions.
  • EVALUATING
     
    • a PLANNED, ONGOING, PURPOSEFUL activity in which clients and HCPs determine:
    a.  Client’s progress towards achievement of goals or outcomes
    b.   the effectiveness of the NCP
  • EVALUATING
    • an important aspect of nursing process because conclusions drawn from the evaluation determine whether the nursing interventions should be terminated, continued or changed. – continuous
  • ·        5 COMPONENTS OF EVALUATION
     
    1. Collecting data related to the desired outcomes
    2. Comparing the data with the desired outcomes
    3. Relating nursing activities to outcomes
    4. Drawing conclusions about problem status
    5. Continuing, modifying, or terminating the nursing care plan
    • Goal met: the client response is the same as the desired outcomes
    • Goal partially met: either a short-term outcome is achieved but the long term was not
    • Goal not met
  • DOCUMENTING AND REPORTING
     
    • Health personnel communicates through: DISCUSSION, REPORTS AND RECORDS
  • DISCUSSION – is an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.
  • REPORT – oral, written or computer-based communication intended to convey information to others.
  • RECORDS –also called CHART or CLIENT RECORD
  • RECORDING, CHARTING, DOCUMENTING - the process of making an entry on the client record           
  • The joint commission requires client record documentation to be:
    • TIMELY
    • COMPLETE
    • ACCURATE
    • CONFIDENTIAL
    • SPECIFIC TO THE CLIENT
  • ETHICAL AND LEGAL CONSIDERATIONS
     
    • The nurse has a duty to maintain confidentiality of all the patient information. (ANA CODE OF ETHICS, 2001)
    • Access to the health record is restricted to health professionals involved in giving care to the client.
    • The institution or agency is the rightful owner of the client’s record.
  • ETHICAL AND LEGAL CONSIDERATIONS
    • For the purposes of education and research, most agencies allow students and graduate health professionals access to client records.
    • The records are used in client conferences, clinics, rounds, client studies, and written papers. à must protect the client’s privacy by not using name or anything that identifies the client.
  • ·        ENSURING CONFIDENTIALITY OF COMPUTER RECORDS
     
    1. A personal password is required to enter and sign off computer files. Do not share this password with anyone, including other health team members.
    2. After logging on, never leave a computer terminal unattended.
    3. Do not leave client information displayed on the monitor where others may see it.
  • ENSURING CONFIDENTIALITY OF COMPUTER RECORDS
    1. Shred all unneeded computer-generated worksheets.
    2. Know the facility’s policy and procedure for correcting an error entry.
    3. Follow agency procedures for documenting sensitive material, such as diagnosis of AIDS.
    4. IT personnel must install a firewall to protect the server from unauthorized access.
  • PURPOSES OF CLIENT RECORDS
     
    1.      COMMUNICATION
    2.      PLANNING CLIENT CARE
    3.      AUDITING HEALTH AGENCIES
    4. RESEARCH
    5.      EDUCATION
    6.      REIMBURSEMENT
    7.      LEGAL DOCUMENTATION
    8.      HEALTH CARE ANALYSIS
  • COMMUNICATION
    • Serves as a vehicle by which different health professionals who interact with a client communicate with each other.
    • prevents fragmentation, repetition and delays in client care.
  • PLANNING CLIENT CARE
    • Each health professional uses data from the client’s record to plan care for the client.
  • AUDITING HEALTH AGENCIES
    • An AUDIT is a review of client records for quality assurance purposes.
    • accredited agencies (philhealth, DOH) may review client records to determine if a particular health agency is meeting its stated health standards
  • RESEARCH
    • information obtained can be valuable source of data for research
  • EDUCATION
    • students in health discipline often use client records as an educational tool.
  • REIMBURSEMENT
    • documentation also helps facility receives reimbursement from the funding agencies (Philhealth, insurance companies, PCSO)
  • LEGAL DOCUMENTATION
    • The client’s record is a legal document and is usually admissible in the court as evidence.
  • HEALTH CARE ANALYSIS
    • Information from records may assist HC planners to identify agency needs such as overutilized or underutilized hospital services.
  • DOCUMENTATION SYSTEMS
     
    • these documentation systems can be implemented using traditional paper or with Electronic Health Records (EHRs)
  • SOURCE-ORIENTED RECORD
     
    • Traditional client record
    • each person or department makes notations in a separate section or sections of the client’s chart
    • information about a particular problem is distributed throughout the record.
    • NARRATIVE CHARTING – is a traditional part of SOR.
     
  • PROBLEM- ORIENTED MEDICAL RECORD
     
    • the data are arranged according to the problems the client has rather than the source of the information.
    • members of the HC team contribute to the PROBLEM LIST, PLAN OF CARE, and PROGRESS NOTES.
    • plans for each active and potential problem are drawn up, and progress notes are recorded for each problem
  • FOUR BASIC COMPONENTS:
     
    • DATA BASE
    • PROBLEM LIST
    • PLAN OF CARE
    • PROGRESS NOTES
    • DATA BASE – consist of all information known about the client when the client first enters the health care agency. Data are constantly updated as the client’s health status changes
    • PROBLEM LIST – derived from the database. It is usually kept at the front of the chart and serves as an index to the number of entries in the progress notes.
    • Problems are listed in the order in which they are identified and the list is continually updated as new problems are identified and other resolved.
    • PLAN OF CARE – initial lists of orders or plan of care is made with reference to the active problem. Care plans are generated by the individual who lists the problems
    • PROGRESS NOTES – is a chart entry made by all health professionals involved in the client’s care; they all use the same type of sheets for notes.
  • S - SUBJECTIVE DATA consist of information obtained from what the client says.
  • O - OBJECTIVE DATA consist of information that is measured or          observed by the use of the senses