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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
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
Are the expected outcomes realistic?
Are the nursing data correlated with the results of the physical examination and findings from diagnostic tests?
Can any assumptions that might have misled the nurse’s judgment be identified?
Did the nurse use the data obtained from both the interview and physical assessment in establishing the diagnoses?
Were critical questions asked during the client interview?
When the defining characteristics of a specific nursing diagnosis are compared to the client’s presenting signs and symptoms, is there supporting evidence?
Can the assessment data that triggered the nursing diagnosis be identified?
5. Describe the latest advances in computerized documentation.
4. Describe various types of documentation records.
3. Describe various methods of documentation.
2. Discuss the principles of effective documentation.
1. Explain the purposes of documentation in health care.
5. Implement change in the process.
4. Formulate improvements.
3. Assess variations.
2. Measure the current process.
1. Identify an important process to evaluate.
Valuing differences of specific groups.
Identifying legal responsibilities
Explaining cultural differences
Discussing assumptions and biases based on gender, race, age, and religion
Identifying individual beliefs and values
7. A scientific approach based on analysis of data is used.
6. Work processes that influence outcome are studied and improved, rather than relying solely on problem solving.
5. Processes and system operation, in addition to individual performance, are monitored.
4. Education and training must be continual to improve skills and promote self-development.
Recruitment and training of new employees
Loss of staff due to job dissatisfaction
Loss of time due to inefficient task performance
Duplicated work between departments
On-site surveys will occur during evenings, nights, and weekends rather than be limited to weekdays(Gropper, 1999).
The focus and scope of the review during the survey will vary from agency to agency.
Health care organizations will no longer receive advance notification of impending random surveys.
Random unannounced surveys will be conducted.
10. Discuss the nurse’s role in quality management.
9. Identify various tools used for quality measurement.
8. List the steps of the scientific approach used in process improvement.
7. Discuss the organizational structure and management factors affecting quality improvement.
6. Explain the concept of customer perspective and its relationship to quality management.
5. Describe basic principles and concepts of quality improvement.
4. Discuss the role of law and ethics in quality care.
3. Identify factors influencing the quality movement in health care.
2. Describe the nine dimensions of quality performance as identified by the Joint Commission on Accreditation of Healthcare Organizations.
1. Discuss the historical development of the quality movement in health care.
The client is a physician.
The client is a nurse.
The client is a member of a very wealthy and influential family.
The client is homeless.
The client is a convicted rapist.
7. What impact does the following information have on your provision of professional care?
A female prostitute who became infected by sharing needles with other drug users
A homosexual male who was infected by a promiscuous partner
A child infected through a contaminated blood transfusion
How do you respond to a client’s decision to continue self-harmful practices?
How will you support a client’s right to refuse treatment?
Do you agree with this statement?
a. Determine some specific behaviors that you can perform to actualize each tenet of the code.b. Identify the ethical principle(s) upon which each ethical statement is based.
Is the harm created by the act of whistle-blowing likely to be less than the harm done by the wrongdoing?
Will reporting of the problem likely correct wrongdoing or prevent future harm?
Have all internal resources been used to resolve the problem?
Has the nurse consulted others to confirm the information?
Has all the appropriate information been collected?
Is the nurse competent to make a judgment about the wrongdoing?
Has the wrongdoing created (or is it likely to create)serious harm?
Facilitate communication of the client’s desires to family and other health care providers
Allow time for the client to explore values and to communicate.
Assess the client’s understanding of the illness and available treatment options.
Initiate dialogue concerning the client’s wishes. Do more listening than talking. (For example, the following is a question you might ask to help determine the client’s wishes: “If your heart stopped, would you want us to try to start it again?”)
Can you ethically justify telling white lies?
Can you ethically justify withholding information?
Is withholding information the same as lying?
8. Discuss the roles of the nurse as client advocate and whistle-blower in the delivery of ethical nursing care
7. Apply the steps identified in the framework for ethical decision making to issues such as euthanasia, refusal of treatment, and utilization of scarce resources.
6. Identify the rights of the client as established by the American Hospital Association.
5. Relate the ethical codes developed by the International Council of Nurses, the American Nurses Association, and the Canadian Nurses Association to daily nursing practice.
4. Explain the link between ethics and values.
3. Describe the major ethical principles that affect health care.
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