Fundamentals 1 exam #2

• Final step in the nursing process
• Determines whether after application of the nursing process, the pt's condition/well-being improves.
• It is an ongoing process
• Occurs after an intervention has been administered.
• During evalution, subjective/objective data are gathered from patient, family, health care teams.
• Knowledge re: pt's current condition,  TX, resources available for recovery, and expected outcome is reviewed.
• Clinical decisions and nursing care is continuously redirected (if needed).
• The intent of evaluation is to determine if the known problem have remained the same, improved, worsened, or otherwise changed. 

The sequence of critically evaluating and revising therapies continues until the nurse and the pt successfully and appropriately resolve the problems defined by the nursing diagnosis..

It's the physiological, emotional, and behavioral responses that are a patient's goals and expected outcomes.

• Examination of a condition or situation
• Judgment as to whether change has occurred.

• The appropriateness of the intervention selected
• The correct application of the intervention.

• It is the expected behavior or response that indicates resolution of a nursing diagnosis or maintenance of a healthy state.
• It's a summary statement of what will be accomplished when the patient has met all expected outcomes.
• Goals are often based on standards of care or guidelines established for minimal safe practice.

• It is the end result that is measurable, desirable, and observable and translates into observable patient behaviors.
• It is a measure that tells the nurse that the intervention applied in patient care led to successful goal achievement.

• When nurses apply the nursing process, a nursing-sensitive outcome is a measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing intervention.
• The intervention must be within scope of practice and integral to the process of nursing care.
• Examples: pain frequency, incidence of pressure ulcer and falls.

• Collaboration with pt or family is important in the evaluation process. 
• Active involvement of the family is important aspects of patient-care centered care. 

• Evaluative measures are assessment skills or techniques such as observations, physiological measurements, and patient review. that a nurse uses to collect data for determining if outcomes were met. 
• It is the same as assessment measure except that it is performed at the point of care when the nurse make decision about the patient's status or progress. 

• Examine the outcome criteria to identify the exact desired pt behavior or response.
• Evaluate the patients actual behavior or response. 
• Compare the established outcome criteria with the actual behavior or response.
• Judge the degree of agreement between outcome criteria and the actual behavior or response.
• If there is no agreement (or partial agreement) between the outcome criteria and the actual behavior or response, what is/are the barrier(s)? Why did they not agree?

• It's a valuable source of data for all members of the health care team. 
• Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring. 

• The patient's record is one way that health care teams members communicate patients needs and progress, individual therapies, content of consultants, patient education, and discharge planning. 
• Information communicated in the pts record allows health care providers to know a patient thoroughly, facilitating safe, effective and timely patient-centered decisions. 

• 1. failing to record pertinent health or drug information
• 2. failing to record nursing actions
• 3. failing to record that medications have been given
• 4. failing to record drug reactions or changes in patients conditions
• 5. writing illegible or incomplete records
• 6. failing to document discontinued medications. 

• The hospital is reimbursed a predetermined dollar amount by Medicare for each Diagnosis-related groups (DRGs). 
• A nurses documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency. 
• Accurate documentation of supplies and equipment used assists in accurate and timely reimbursement. 

Diagnoes, signs and symptoms of disease, successful and unsuccessful therapies, diagnostic findings, patient behaviors. 

• Nurse researchers use patients record for research studies to gather statistical data on the frequency of clinical disorders, complication, use of specific medical and nursing therapies, recovery from illness, and deaths. 
• Researches also use this information to investigate nursing interventions or health problems. 

Quality improvement programs keep nurses informed of standards of nursing practice to maintain excellence in nursing care. This maintained by using pts records

factual, accurate, complete, current, and organized

• objective information about what a nurses sees, hears, feels, and smells. 
• It includes pts behavior. 
• Do not use vague terms such as "appears, seems, or apparently" b/c these suggest a nurses opinion. 
• The only subjective data included in record are what the patient says in quotation. 
• Include objective data to support subjective data so the charting is as descriptive as possible. 

• VS
• Pain assessment
• Administration of medication and treatments
• Preparation for diagnostic tests or surgery, including preoperative checklist.
• Change in patient's status and who was notified (e.g. MD, pt family)
• Admission, transfer, discharge, or death of a patient
• Treatment for sudden change in patients status
• Patient's response to treatment or intervention.

• traditional method for recording nursing care, that simply uses a story-like format to document information specific to patient conditions and nursing care. 
• Disadvantages are that it can be repetitious and time consuming and requires the reader to locate desired data. 

POMR is a method of documentation that emphasizes patients problem. Data are organized by problem or diagnosis. It contains four major sections: database, problem lists, care plan, and progress note. 

• S - subjective data (verbalization of patient)
• O - Objective data (that which is measured and observed)
• A - Assessment (diagnosis based on the data)
• P - plan (what the caregiver plans to do)

• I - intervention
• E - evaluation

• P - problem
• I - intervention
• E - evaluation

• PIE is problem-oriented
• PIE notes are numbered and labeled according to pt's problem. 

It involves the use of DAR (data (sub/obj), action (nursing intervention), and response (evaluation of effectiveness). It addresses the patient concern: s/s, condition, nursing diagnosis, behavior, significant event, or change in patients condition. 

CBE focuses on deviations from norm. Progress notes are only written only when there are deviations from the norm. 

Its a model of delivery care that incorporates an interdisciplinary approach to documenting patient care. 

• Its interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established time frame. 
• It eliminates flow sheets, nurses notes, and nursing care plans b/c document integrates all relevant information.