tailieunhanh - Lecture Nursing documentation using electronic health records: Chapter 6 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 4 - Nurse note documentation, level 2. After completing Chapter 6, the students will be able to: Use NANDA-International (NANDA-I) approved nursing diagnoses to reflect patient needs, identify patient specific goals using Nursing Outcomes Classification (NOC), identify and document nursing interventions using Nursing Intervention Classification (NIC), carry out documentation of medication administration, carry out documentation of intake and output (I&O). | Chapter 6 Nurse Note Documentation Level 2 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 6 Content LO Dx (Nursing Diagnosis) LO NOC (Nursing Outcomes) LO NIC (Nursing Interventions) LO MAR (Medication Administration Record) LO I&O (Intake and Output) LO DX (NURSING DIAGNOSIS) LO Dx (Nursing Diagnosis) Standardized language Mechanism for communication Reflects nursing practice Facilitates use of technology Allows comparison of nursing activities Used in research Promotes quality patient care 12 systems recognized by ANA LO Dx (Nursing Diagnosis) NANDA-I nursing dx, NOC, NIC Widely recognized Research based Comprehensive LO Dx (Nursing Diagnosis) Nursing process Assessment/diagnosis Planning Intervention Evaluation LO Dx (Nursing Diagnosis) Assessment First step in nursing process Subjective data Report of patient and/or family Objective data Observations of nurse Observation Auscultation Palpation Smell LO . | Chapter 6 Nurse Note Documentation Level 2 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 6 Content LO Dx (Nursing Diagnosis) LO NOC (Nursing Outcomes) LO NIC (Nursing Interventions) LO MAR (Medication Administration Record) LO I&O (Intake and Output) LO DX (NURSING DIAGNOSIS) LO Dx (Nursing Diagnosis) Standardized language Mechanism for communication Reflects nursing practice Facilitates use of technology Allows comparison of nursing activities Used in research Promotes quality patient care 12 systems recognized by ANA LO Dx (Nursing Diagnosis) NANDA-I nursing dx, NOC, NIC Widely recognized Research based Comprehensive LO Dx (Nursing Diagnosis) Nursing process Assessment/diagnosis Planning Intervention Evaluation LO Dx (Nursing Diagnosis) Assessment First step in nursing process Subjective data Report of patient and/or family Objective data Observations of nurse Observation Auscultation Palpation Smell LO Dx (Nursing Diagnosis) Assessment data used to formulate nursing dx Nursing diagnosis “Clinical judgment about individual, family, or community experiences and responses to actual or potential health problems and life processes” (NANDA-I) Key = patient response to illness Medical diagnosis Disease process LO Dx (Nursing Diagnosis) Nursing diagnosis Prioritized High priority = Airway, Breathing, Circulation (ABCs) Mid priority = threat to health or ability to cope Low priority = delayed intervention will not cause harm LO Dx (Nursing Diagnosis) To assign nursing dx Collect subjective and objective data Analyze data to identify actual and potential problems Assign nursing dx Individualize nursing dx Etiology (related to) Signs & symptoms (as evidenced by) Place in order of priority LO Dx (Nursing Diagnosis) Research evidence Use of nursing diagnoses improves documentation of assessments Inclusion of etiology in nursing dx improves both interventions and outcomes Muller-Staub,