Nursing Process/Documentation Care Plan: Adpie : Hint Hint

Chapter 9
Hint Hint
Nursing Process/Documentation
CARE PLAN: ADPIE
Student Copy and Instructor Copy
Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.
Nursing Process: ADPIE

Series of five steps that lead to
accomplishing some goal or purpose:
1.
2.
3.
4.
5.
Assessment
Diagnosis
Planning and outcome identification
Implementation
Evaluation
(continued)
Nursing Process
Systematic method for providing care to
clients
Provides individualized, holistic, effective,
and efficient client care
Applies to clients of all ages in any care
setting
1st STEP: Purposes of Assessment

Organize database regarding clients
physical, psychosocial, and emotional
health
How? *Meet/greet patient the day before
your 2-day clinical rotations.
Identify health-promoting behaviors and
actual and/or potential health problems
How? *Read CHART ex: Adm notes,
SW notes, RD notes, PT notes
Types of Assessment
(1) COMPREHENSIVE--Baseline client data
Examples: current state of health, family
history, and PE. This information is found
the hospital admission assessment form and
health history assessment form
(2) FOCUSED--Limited to particular need or

health care concernn
Example:Discussingwithclientanyhealth
concernsorgoalsthattheymayhave
(3) ONGOING-- Systematic monitoring of

specific problems Ex:HTNclientat7am
Sources of Data (*best choice)

1 Primary: *Client
Client or major provider of

information about client
2 Secondary: *Clients medical
record/chart
Sources of data other than client
Examples: family members, other health
care providers, medical records.
Types of Data
(1) Subjective
my leg hurts 5/10
Data from clients point of view

Perceptions, feelings, and concerns
Collected by interview
(2) Objective
pt limping.
Observable
Measurable
Obtained through physical examination and lab
and diagnostic testing
(continued)
Interpreting the Data

Organizing data in clusters helps find
patterns of response or behavior
Distinguish between relevant and irrelevant
Determine whether and where gaps exist in data
Identify patterns of cause and effect
During an initial assessment the

nurse notes that the pt. reports
being unable to walk more than 5
steps without SOB. Which?
A. Elimination
B. Sleep/Rest Inactivity
C. Coping/Stress Intolerance
D. Activity/Exercise
Documenting the Data involves

critical thinking
Nurses must decide which data should be
immediately reported and which can just be
recorded
Think about what you need to document to protect
LPN license in case taken to court
Essential for accurate and complete recording of
assessment data to communicate information to
other health care team members
Do not document what you think, feel or want.
2nd STEP: Nursing NANDA Diagnosis

Clinical judgment about individual, family, or
community response to actual or potential health
problems or life processes providing basis of care
How does a nursing Dx differ from a medical Dx?
A.Nrs Dx is a clinical judgment about family, pt or
community response to actual or potential problems
B.Nrs Dx is a clinical judgment identifying a disease
C.Only a doctor can make a medical Dx but anyone
can make a nrs Dx
D.The doctor defines medical intervention after a
nursing diagnosis is successfully determined
(continued)
Diagnosis
Clients have both NANDA nursing and
medical diagnoses- (clinical judgment by
physician that identifies or determines
specific disease, condition, or pathological
state)
Can only occur when the clients data is
broken down into parts that can be
examined and analyzed.
3 Types of Diagnoses
(1) Actual --- Indicates problem exists
Example-The pt suffered a mild stroke leading to a
change in the clients health status.. Anxiety attack
and cant go outside her home anymore..
(2) Risk/Potential For -- Indicates potential

problem where specific risk factors are
present
(3) Wellness--Clients statement of desire to
attain higher level of wellness in some area of
function
Care Plan: Readiness for enhanced spiritual wellbeing
(continued)
3rd STEP: Planning and Outcome

Identification
Third step of nursing process:
Establish guidelines for proposed course of nursing

action focusing on the problem
Develop clients plan of care
Whats the aim or intent
Planning Phases
Initial - STG
Developing clients preliminary plan of care
Ongoing - STG or LTG

Updating clients plan of care
Discharge - LTG
Anticipating and planning for clients needs after
discharge
GCC LPN Program Requirements:

due 0700 a.m. on 1st clinical day
1st Spring Semester
1 care plan
1 STG + 1 LTG with 3 interventions each
2nd Summer Semester

1 care plan
2 STGs + 1 LTG with 3 interventions each
3rd Fall Semester

2 Care Plans
2 STGs + 1 LTG with 3 interventions each
Components of Planning
Prioritizing nursing diagnoses
Identifying and writing client-centered
long- and short-term goals and outcomes
Identifying specific nursing interventions
Recording entire nursing care plan in
clients record
Nursing Interventions
Actions performed by nurse/stdnt nurse
to help client achieve results specified by
goals and expected outcomes
Refer directly to related factors or risk
factors in nursing diagnoses
Are stated in specific terms
May change
Categories of Nursing Interventions

Independent
Initiated by nurse
Do not require order
Dependent
-Requires MD Rx or
another health prvdr
Interdependent
Implemented in collaborative manner by nurse in
conjunction with other health care professionals
** MAKE SURE INTERVTNS

ARE REALISTIC! What does
this mean?
(continued)
Nursing Care Plan

Written guide of strategies to be
implemented to help client achieve optimal
health
Begins on day of admission and continues
until discharge (aka LTG)
4th STEP: Implementation

GCC Rationales
Fourth step in nursing process:
Performance of nursing interventions identified during
planning phase
Student nurse must explain to the instructor

why you think your goal and intervention
are appropriate for your assigned patient.
Refer to your textbooks for a professional
medical rationale/professional response.
Orders for Interventions

Specific order
For individual client
Protocol or Standing Order
Series of standing orders or procedures
Example:
1. Oxygen 2-4L via NC for SOB or
OxSat < 90%
2. Give OJ 6oz if DM BS<60 mg/dL
Documenting and Reporting

Interventions
Information to be communicated:
Activities completed and not completed

Status of current relevant problems
Assessment changes or abnormalities
Results of treatments
Diagnostics tests scheduled and completed
5 STEP: Evaluation
th
This final step involves the execution of the

nurse implementation derived from the care
plan + determines how successful the pt.
met his/her goals
Determines whether client goals have been met, partially
met, or not met
Ongoing evaluation essential for nursing process to be
implemented appropriately
LPN-SN ASK YOURSELVES:
(1)Was the STG met? Write yes or no
(2)If STG was NOT met, why not? Was it realistic?
Inadequate time frame? Was your nursing intervention
appropriate?
Nursing Process and Critical Thinking

Critical thinking can be learned by:
Asking questions
Identify assumptions + staying away from
them
Evaluate evidence: do you have EB proof?
Examine alternatives: What else?
Seek to understand various points of view
thinkthink..think.before talking
Listen more than talk.
Which of these statements about the

relationship between nursing process and
critical thinking is TRUE?
A. The nurse must use critical thinking in
every component of the nursing process
B. Critical thinking is important to the nurse
during the assessment phase
C. Critical thinking is important to the nurse
primarily during the evaluation phase
D. Critical thinking can not be learned but the
nursing process can be learned
Documentation
Most essential nursing communication tool
because it confirms the care provided to
the pt. and outlines crucial information
about the pt.
Any printed or written record of activities
Recording and reporting
Major ways health care providers communicate
Clients medical record

Legal document of all activities regarding client care
Purposes of Documentation
Communication
Practice and legal standards
Reimbursement
Education
Research
Nursing audit
Communication
Documentation confirms care provided to
client and clearly outlines all important
information regarding client
Practice and Legal Standards

Legal aspects of documentation require:
1. Must be factual
Do not include feelings, thoughts, or suggestions
2. Legible, neat writing
3. Proper spelling and grammar
4. Use of authorized abbreviations
Can not use BFF, BTW, LOL, OMG
5. Time-sequenced and descriptive entries
If not able to meet time(s) write late entry
Practice Standards Include

Nursing Practice Act est. guidelines
for practice and standards of care that
are evidence by documentation
The Joint Commission-req. process of plan of care be
developed and documented
HIPAA-Confidentiality + privacy regulations

Informed consent-req. pt can not be sedated and
must be witnessed
Advance directives-only used if pt. cannot make
own medical decisions
Education
Health care students use medical record as
tool to learn about disease processes, nursing
diagnoses, complications, and interventions
Students can enhance critical-thinking skills
by examining records and following health
care teams plan of care
Nursing Audit:
#1 key factor to many malpractice
cases is inadequate documentation!
Method of evaluating quality of care,
including:
Safety measures
Treatment interventions and responses
Expected outcomes
Client teaching
Discharge planning
Adequate staffing
12 Principles of Effective
Documentation
The Dos of charting!!!!
1. Document accurately, completely, and
objectively
Including any errors
2. Note date and time

3. Use appropriate forms
4. Identify client
(continued)
Principles of Effective Documentation

5.
6.
7.
8.
9.
Usually write in black ink

Use standard abbreviations
Spell correctly
Write legibly
Correct errors properly crossing out the
entry with a single line; then write initials
with date and time aka mistaken entry.
(continued)
Principles of Effective Documentation

10.Write on every line
11.Chart omissions
12.Sign each entry
Use same guidelines for GMHA/SNU
IMED computer system
Forms for Documentation

GCC Nursing Students:
Look at these documents the day before your
2-day SNU clinical rotations
Kardex
Flow sheets
Nurses progress notes
Discharge summary
Social Worker notes
Referral notes

Nursing Process/Documentation Care Plan: Adpie : Hint Hint

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Nursing Process/Documentation Care Plan: Adpie : Hint Hint

Загружено:

Авторское право:

Доступные форматы

Chapter 9

Nursing Process: ADPIE

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

1st STEP: Purposes of Assessment

(2) FOCUSED--Limited to particular need or

(3) ONGOING-- Systematic monitoring of

Sources of Data (*best choice)

Client or major provider of

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

my leg hurts 5/10

Data from clients point of view

Interpreting the Data

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

During an initial assessment the

Documenting the Data involves

2nd STEP: Nursing NANDA Diagnosis

(2) Risk/Potential For -- Indicates potential

3rd STEP: Planning and Outcome

Third step of nursing process:

Establish guidelines for proposed course of nursing

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Ongoing - STG or LTG

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

GCC LPN Program Requirements:

2nd Summer Semester

3rd Fall Semester

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Categories of Nursing Interventions

** MAKE SURE INTERVTNS

Nursing Care Plan

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

4th STEP: Implementation

Student nurse must explain to the instructor

Orders for Interventions

Documenting and Reporting

Activities completed and not completed

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

This final step involves the execution of the

Nursing Process and Critical Thinking

Which of these statements about the

Clients medical record

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Practice and Legal Standards

Practice Standards Include

HIPAA-Confidentiality + privacy regulations

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

2. Note date and time

Principles of Effective Documentation

Usually write in black ink

Principles of Effective Documentation

Copyright 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Forms for Documentation

Вам также может понравиться