test 1 np 2 Flashcards
charting, documentation, elimination, specimen collection.
Acuity charting
Typically, nurses enter acuity data into a computerized documentation system in the morning. The administrative staff collects the acuity data electronically and uses it to make appropriate staffing decisions. Acuity levels allow the nursing staff to compare patients with one another. For example, an acuity system might rate bathing patients from 1 to 5 (1 is totally dependent, 5 is independent), whereas a patient returning from surgery who requires frequent monitoring and extensive care has an acuity level of 1.
Charting by exception (CBE)
is a system of documentation that aims to eliminate redundancy, makes documentation of routine care more concise, emphasizes abnormal findings, and identifies trends in clinical care. Documentation is more effective, nurses spend less time charting, data is easy to retrieve, and communica¬ tion is improved (Guido, 2006). CBE is a shorthand method for documenting based on clearly defined standards of practice and predetermined criteria for nursing assessments and interventions. This system involves completing a flow sheet that incorporates standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal findings and routine interventions. You write a narrative nurse’s note only when there is an exception to the established standard or abnormal data are present.
Computer-based patient care record (CPCR)
A system that contains electronically maintained information about an individual’s health status and care. It focuses on tasks directly related to patient care, unlike other healthcare information systems that support providers’ and payers’ operational processes. The CPR completely replaces the paper medical chart and thus must meet all clinical, legal and administrative requirements.
Critical pathways
Case management programs use a multidisciplinary plan of care summarized into critical pathways. The critical pathways are mul¬ tidisciplinary care plans that include key interventions and ex¬ pected outcomes within an established time frame (see Fig. 4-5). Critical pathways are evidence based, and the assessment/monitor¬ ing, interventions, and expected outcomes are based on research and/or clinical evidence within the literature.
Critical pathways state the goals and important elements of care based on best practice and patient expectations by documenting, monitoring, and evaluating variances and providing resources and outcomes. Variances are unexpected occurrences, unmet goals, and interventions not specified within the critical pathway time frame and reflect a positive or negative change.
DAR
D (Data): Patient states, “I am dreading this surgery because last time I had a terrible reaction to the anesthesia and had such terrible pain when they made me get out of bed.” Noted muscle tension and loud, agitated voice.
A (Nursing Action): Notified anesthesiologist, Dr. M, of patient’s prior experience. Discussed alternatives for anesthesia and paincontrol options. Stressed importance of activity for circulation/healing. Encouraged to keep nurses informed of pain level/need for medication and that pain may be present, but manageable.
R (Patient Response): Patient stated she was “very relieved.” Stated understanding of the importance of informing the nurses about pain.
Note: Some agencies add P (Plan) and refer to this as DARP charting.
Example: P (Plan): Assess pain level at least every 4 hours postoperatively.
Provide nonpharmacological pain management techniques, and ad¬ minister medication as needed.
Evidence-based practice
EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal preferences and unique concerns, expectations, and values. The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology.
Flow sheet
Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements for a patient such as vital signs, intake and output hygiene, medication administration, and pain assessment. Flow sheets use a system for entry of information. When documenting a significant change that appears on a flow sheet, you describe the change in the progress notes, including the patient’s response to nursing interventions.
Focus charting
One distinction of focus charting is it places less importance on patient problems and focuses on patient concerns such as a sign or symptom, condition, a nursing diagnosis, a behavior, a significant event, or a change in condition. Each documentation includes data (both subjective and objective), actions or nursing interventions, and patient response (e.g., evaluation of effectiveness). Nurses need to broaden their thinking to include any patient concerns, not just problem areas, and to apply critical thinking. Focus charting saves time because it is easy for caregivers to understand and is adaptable to most health care set¬ tings, and it enables all caregivers to track a patient’s condition and progress.
Incident report
An incident is any event not consistent with the routine operation of a health care unit or routine care of a patient. Examples include patient falls, needle-stick injuries, medication errors, or a visitor becoming ill. Completion of an incident report occurs when there is actual or potential patient injury and is not part of the patient record. Document in the patient’s record an objective description of what you observed and follow-up actions taken without reference to the incident report. Reporting of incidents helps in the identification of high-risk trends in nursing care or daily unit operations that warrant correction.
Kardex
a Kardex (“flip-over” file) kept at the nurses’ station provides information for daily patient care needs. It has two parts: an activity and treatment section and a nursing care plan section. The updated information in the Kardex eliminates the need for repeated referral to the chart for routine information throughout the day.
Information commonly found on the patient care summary or Kardex includes the following: • Basic demographic data (e.g., age, religion) • Primary medical diagnosis • Current physician’s or health care provider’s orders (e.g., diet, activity, dressing changes)
• A nursing care plan • Nursing orders or nursing interventions (e.g., intake and out¬ put, comfort measures, teaching)
• Scheduled tests and procedures • Safety precautions used in the patient’s care • Factors related to activities of daily living • Nearest relative/guardian or person to contact in an emergency
• Emergency code status • Allergies
SOAP (IE) charting,
S: Subjective data (patient statements about the problem)
O: Objective data (data that are measured and observed or related to subjective data)
A: Assessment/Analysis (conclusions based on the subjective and objective data)
P: Plan (what the caregiver plans to do)
Objective data
data that are measured and observed or related to subjective data. (e.g., rash, tenderness, breath sounds)
PIE
P: Problem or nursing diagnosis for the patient I: Interventions or actions taken E: Evaluation of the outcomes of nursing interventions
Transfer reports
3 units of transfer
from emerge to room, to x-ray or another department, discharge
Problem-oriented medical record (POMR),
is a structured method of documentation that emphasizes a patient’s problems. This method is organized using the nursing process, which facili¬ tates communication about patient needs. Data are organized by problem or diagnosis. Ideally, all members of the health care team contribute to the list of identified patient problems. This approach assists in coordinating an individualized plan of care with the fol¬ lowing sections: database, problem list, care plan, and progress notes.
Narrative charting
Narra¬ tive charting uses a storylike format to document specific informa¬ tion about a patient’s conditions and nursing care, usually pre¬ sented in chronological order. Narrative charting is useful in emergency situations when the time and order of events is impor¬ tant.
Standardized care plan
The plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. After completing a nursing assessment, place an appropriate standardized care plan in the patient chart. You individualize standardized care plans for each patient. Most standardized care plans allow for the addition of patient-specific outcomes and target dates for achievement of these outcomes.
- advantage of standardized care plans is the establishment of evidence-based standards of care. By using standardized plans, nurses learn to recognize the accepted requirements of care for patients. The standardized care plans also improve continuity of care among professional nurses. The Joint Commission supports the use of standardized care plans and no longer requires a written care plan for each patient.
- disadvantage of standardized care plans is an increased risk that the unique, individualized therapies needed by patients will go unrecognized. Standardized care plans do not replace your professional judgment and decision making. In addition, care plans need updating on a regular basis to ensure that content is current and appropriate.
Subjective data
Description of episode/event in patient’s words in quotation marks
Clarify onset, location, description of condition (severity; duration; frequency; precipitating, aggravating, and relieving factors)
nursing process
Nursing process helps nurses organize and deliver nursing care. It is a systematic approach that applies knowledge from the biological, physical, and social sciences to unique client situations. It is used to identify, diagnose, and treat human responses to health and illness. The nursing process involves five steps: assessment, nursing diagnosis, planning, implementation and evaluation.
why client expectations are important in the nursing process.
=
the importance of the nursing health history.
A comprehensive nursing history form provides baseline assess¬ ment data and is completed when a patient is admitted to a nursing care unit. You will use the admission data later to compare it to any changes in the patient’s condition. The form guides the admitting nurse through a complete assessment to identify relevant nursing diagnoses or problems for the patient’s care plan.
difference between a goal and an expected outcome
=
