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statistics for nursing a practical approach
Fundamentals Of Nursing: Standards And Practices 2nd Edition Sue C. DeLaune, Patricia Kelly Ladner - Solutions
Client data: Name, age, marital status, religious preference
Supports multidisciplinary networking: Information is quickly coordinated and integrated by other departments; all departments have access to the data.
Enhances critical thinking and decision making:Provides access to other data, such as laboratory results, that can be correlated with the nurses’ assessment data. If a trend is developing (e.g., decreasing levels of oxygenation), the nurse will recognize it quickly.
Enhances implementation of the nursing process:Uses documentation tools that provide an individualized plan of care: admission and nursing history data, diagnosis, goals, measurable outcomes, and interventions, inclusive of client teaching. Improved documentation of interventions has improved the
Facilitates statistical analysis of data.
Provides clear, decisive, and concise key words:Standardized nursing terminology provides for usage of consistent key words (e.g., alert) and avoids ambiguous phraseology (e.g., “appears to be”).Nurses can select nursing choices on a screen that automatically builds a comprehensive record of an
Increases legibility and accuracy: A computer printout is easy to read and legible. Accuracy is achieved through standardized documents that prompt the nurse for information, making the charting more complete, thorough, concise, and organized. For example, the fall-prevention standard is
Saves documentation time: Data entry needs to be done only once; the system avoids duplication of effort. For example, a physician’s medication order goes immediately to the pharmacy, eliminating the need to transcribe and transmit orders; the pharmacy receives the order (at preestablished
Progress notes: Charting based on the SOAP, SOAPIE, or SOAPIER format.
Initial plan: Based on problem identification; the starting point for care plan development with client participation in setting goals, expected outcomes, and learning needs.
Problem list: Derived from the database: a listing of the client’s problems as identified, with each problem numbered and labeled as acute, chronic, active, or inactive. Nurses use NANDA terminology in writing client problems as nursing diagnoses; the list is revised as new problems arise and
Database: Assessment data, representative of all disciplines(history, physical, nursing admit assessment, laboratory findings, educational and discharge needs), which become the basis for a problem list evaluation of the client’s condition.
The information is difficult to retrieve. The same problems may not be addressed from shift to shift, so it is difficult to track the client’s progress. Auditors often disallow charges for equipment and supplies because consistent usage cannot be identified.
It is time-consuming. The paragraphs are free-flowing, so it takes more time to record accurate data and for others to read it.
It fails to reflect the nursing process. The focus is on tasks without emphasis on assessment data or progress toward achievement of outcomes.
The flow of care is disorganized. It is difficult to show a relationship between data and critical-thinking skills. Each nurse writes with a unique style, making continuity of care difficult to identify.
2. Document the error in the nurses’ notes as follows:name and dosage of the medication; time it was given; client’s response to the medication; name of the practitioner who was notified of the error; time of the notification; nursing interventions or medical treatment to counteract the error;
Revisions of planned care: Document the reasons for the revisions with the supporting evidence and client and family agreement.1. Chart the medication on the MAR to prevent other caregivers from giving the client additional doses of the drug, or similar drugs, or drugs that may be contraindicated.
Evaluation: Evaluate and document the effectiveness of the interventions in terms of the expected outcomes:progress toward goals; client response to tests, treatments, and nursing interventions; client and family response to teaching and significant events; questions, statements, or complaints
Implementation: After the intervention has been performed, document on the flow sheet and progress notes observations, treatments, teaching, and related clinical judgments. Client teaching should include learning needs, teaching plan content, methods of teaching, who was taught, and the client’s
Outcome identification and planning: Discuss with the client and communicate to members of the multidisciplinary team the expected outcomes or goals of client care.
The client or family voices a complaint
Measuring the client’s response to an intervention or expected outcome
A change occurs in the client’s condition
Accurately including any errors that occurred.The following discussion of effective charting refers to all nursing documents, such as flow sheet, progress notes, and so on. Add to the nursing documents when:
Factual and time-sequenced organization.
Use of only authorized abbreviations and symbols.
Legibility and neatness.
Use of a common vocabulary.
Describe what you observed, not what you did
Document any change in the client’s condition during a visit or from previous visits.
Use the face of the clock to describe findings that are in a circular pattern (e.g., breast, tympanic membrane, rectum, vagina).
Refer to findings using anatomical landmarks (e.g., left upper quadrant [of abdomen], left lower lobe [of lung], midclavicular line, etc.).
Draw pictures when appropriate (e.g., location of scar, masses, skin lesion, decubitus, deep tendon reflex, etc.).
Do not make relative statements about findings (e.g., “mass the size of an egg”); use specific measurements (e.g., “mass 3 cm × 5 cm”).
State time intervals precisely (e.g., “every 4 hours,” “bid,”instead of “seldom,” “occasionally”).
Avoid evaluative statements (e.g., “client is uncooperative,”“client is lazy”); cite instead specific statements or actions that you observe (e.g., “client said ‘I hate this place’ and kicked trash can”).
Avoid using judgmental language such as “good,” “poor,”“bad,” “normal,” “abnormal,” “decreased,” “appears to be,”and “seems.”
Document any parts of the assessment that are omitted or refused by the client.
Record all data that contribute directly to the assessment(e.g., positive assessment findings and pertinent negatives).
Document all telephone calls that you make or receive that are related to a client’s case.
Document in a complete but concise manner by using phrases and abbreviations as appropriate.
Use a permanent-ink pen (black is usually preferable because of its ability to photocopy well).
Write legibly.
Document in chronological order (if chronological order is not used, state why).
Use quotation marks to indicate direct client responses(e.g., “I feel lousy”).
Never change another person’s entry, even if it is incorrect.
If an error is made while documenting, use a single line to cross out the error, then date, time, and sign the correction(check institutional policy); avoid erasing, crossing out, or using correction fluid.
Do not leave space between entries.
Sign each entry with your full legal name and with your professional credentials, or per your institutional policy.
Date and time each entry.
Document as soon as the client encounter is concluded to ensure accurate recall of data (follow institutional guidelines on frequency of charting).
Ensure that you have the correct client record or chart and that the client’s name and identifying information are on every page of the record.
Interdisciplinary planning and implementation of all aspects of care
The involvement of the client or family in the development of the plan, which must be documented in the medical record
Factual and time-sequenced descriptive notations
Use of authorized abbreviations
Proper use of spelling and grammar
Legible and neat writing
what is the
Activities permitted: Functional limitations, assistance needed in activities of daily living, and safety precautions
Medical orders: Diet, medications, IV therapy, treatments, diagnostic tests and procedures (inclusive of dates and results), and consultations
Nursing diagnoses: Listed by priority
Medical diagnoses: Listed by priority
Client data: Name, age, marital status, religious preference
Supports multidisciplinary networking: Information is quickly coordinated and integrated by other departments; all departments have access to the data.
Enhances critical thinking and decision making:Provides access to other data, such as laboratory results, that can be correlated with the nurses’ assessment data. If a trend is developing (e.g., decreasing levels of oxygenation), the nurse will recognize it quickly.
Enhances implementation of the nursing process:Uses documentation tools that provide an individualized plan of care: admission and nursing history data, diagnosis, goals, measurable outcomes, and interventions, inclusive of client teaching. Improved documentation of interventions has improved the
Facilitates statistical analysis of data.
Provides clear, decisive, and concise key words:Standardized nursing terminology provides for usage of consistent key words (e.g., alert) and avoids ambiguous phraseology (e.g., “appears to be”).Nurses can select nursing choices on a screen that automatically builds a comprehensive record of an
Increases legibility and accuracy: A computer printout is easy to read and legible. Accuracy is achieved through standardized documents that prompt the nurse for information, making the charting more complete, thorough, concise, and organized. For example, the fall-prevention standard is
Saves documentation time: Data entry needs to be done only once; the system avoids duplication of effort. For example, a physician’s medication order goes immediately to the pharmacy, eliminating the need to transcribe and transmit orders; the pharmacy receives the order (at preestablished
Progress notes: Charting based on the SOAP, SOAPIE, or SOAPIER format.
Initial plan: Based on problem identification; the starting point for care plan development with client participation in setting goals, expected outcomes, and learning needs.
Problem list: Derived from the database: a listing of the client’s problems as identified, with each problem numbered and labeled as acute, chronic, active, or inactive. Nurses use NANDA terminology in writing client problems as nursing diagnoses; the list is revised as new problems arise and
Database: Assessment data, representative of all disciplines(history, physical, nursing admit assessment, laboratory findings, educational and discharge needs), which become the basis for a problem list evaluation of the client’s condition.
The information is difficult to retrieve. The same problems may not be addressed from shift to shift, so it is difficult to track the client’s progress. Auditors often disallow charges for equipment and supplies because consistent usage cannot be identified.
It is time-consuming. The paragraphs are free-flowing, so it takes more time to record accurate data and for others to read it.
It fails to reflect the nursing process. The focus is on tasks without emphasis on assessment data or progress toward achievement of outcomes.
The flow of care is disorganized. It is difficult to show a relationship between data and critical-thinking skills. Each nurse writes with a unique style, making continuity of care difficult to identify.
2. Document the error in the nurses’ notes as follows:name and dosage of the medication; time it was given; client’s response to the medication; name of the practitioner who was notified of the error; time of the notification; nursing interventions or medical treatment to counteract the error;
Revisions of planned care: Document the reasons for the revisions with the supporting evidence and client and family agreement.1. Chart the medication on the MAR to prevent other caregivers from giving the client additional doses of the drug, or similar drugs, or drugs that may be contraindicated.
Evaluation: Evaluate and document the effectiveness of the interventions in terms of the expected outcomes:progress toward goals; client response to tests, treatments, and nursing interventions; client and family response to teaching and significant events; questions, statements, or complaints
Implementation: After the intervention has been performed, document on the flow sheet and progress notes observations, treatments, teaching, and related clinical judgments. Client teaching should include learning needs, teaching plan content, methods of teaching, who was taught, and the client’s
Outcome identification and planning: Discuss with the client and communicate to members of the multidisciplinary team the expected outcomes or goals of client care.
The client or family voices a complaint
Measuring the client’s response to an intervention or expected outcome
A change occurs in the client’s condition
Accurately including any errors that occurred.The following discussion of effective charting refers to all nursing documents, such as flow sheet, progress notes, and so on. Add to the nursing documents when:
Factual and time-sequenced organization.
Use of only authorized abbreviations and symbols.
Legibility and neatness.
Use of a common vocabulary.
Describe what you observed, not what you did
Document any change in the client’s condition during a visit or from previous visits.
Use the face of the clock to describe findings that are in a circular pattern (e.g., breast, tympanic membrane, rectum, vagina).
Refer to findings using anatomical landmarks (e.g., left upper quadrant [of abdomen], left lower lobe [of lung], midclavicular line, etc.).
Draw pictures when appropriate (e.g., location of scar, masses, skin lesion, decubitus, deep tendon reflex, etc.).
Do not make relative statements about findings (e.g., “mass the size of an egg”); use specific measurements (e.g., “mass 3 cm × 5 cm”).
State time intervals precisely (e.g., “every 4 hours,” “bid,”instead of “seldom,” “occasionally”).
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