Transcript Documentation

Step 3：Analyze nursing diagnoses
relationships
 Draw lines between nursing diagnoses to indicate
relationships.
 Prepared to verbally explain to your clinical faculty
why you have made these links if it is not obvious.
 Concept mapping is a holistic approach to patient
care.
 This step focuses on the relationships between
diagnoses and the labeling of nursing diagnoses .
Step 4：Identifying goals, outcomes,
and interventions
 Write patient goals and outcomes and then list
nursing interventions to attain the outcomes for
each of the numbered diagnoses on your map.
 The nursing interventions should include
appropriate treatments and medications and
patient teaching.
 Prepared to verbally explain the goals and
rationales for nursing interventions with your
clinical faculty.
Step 5：Evaluate patient’s responses
 This step is the written evaluation of the
patient’s physical and psychosocial
responses.
 It also involves writing your clinical
impressions and inferences regarding the
patient’s progress toward expected
outcomes and the effectiveness of your
interventions to bring these outcomes about.
Documentation
 Documentation involves correctly identifying
patient assessment data to record about a
problem, determining what to record about
the interventions to correct the problem, and
describing the patient’s responses to the
interventions.
 Concept map care plans as the basis of
documentation --- detail in chapter 7
Medication Administration
 Organizing the drugs to be administered
 Relationship of the drug to the problem
 Interacting effects of the drug related to the
total clinical picture.
 Example: Digitalis -- Decreased cardiac output
。what is the relationship between low levels
of Potassium and digitalis?
。assessing the patient carefully for adverse
reactions to the drug.
Nursing Standards of Care
 Standards of the American Nurses Association
 general standards of care
 Standards of the Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO)
 specific policies and procedures
 Standardized nursing care plans
 based on typical nursing diagnoses
Nursing Standards of Care--con’s
 Patient education standards
 appropriate for the patient’s individual needs
and ability
 Insurance agency & government care standards
 clinical pathway / critical pathway
 Utilization review standards
 review charts. Judge the necessity and
appropriateness of care and efficiency with
which care is delivered.
Managed Care in Hospital Settings
 There is a direct relationship between the
care standards described above and the
management of care.
 Hospital-based nurse case managers
assigned to monitor and coordinate their
progress through the health-care system.
 To make links for patients to home health
services, transitional care units, long-term
care facilities, and other agencies to
provide quality care.