What is the purpose of the medical record?
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, 1. communication
2. legal documentation
3. financial reimbursement
4. education/research
5. audit/monitoring
PRIORITIZE NURSING DIAGNOSIS
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Ex: Client s/p colon resection day 1
• Deficient knowledge
• Risk for ineffective airway clearance
• Nutrition less than body requirements
•Acute pain
1st - ineffective airway clearance
2nd - take care of pain
3rd -knowledge deficient
What does DAR mean?
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data, action, response
Implement
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, carry out the plan of care
What is PIE? and how is it different?
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Dx, interventions, evaluation; includes a nursing origin but not assessment
info
1. Read the following patient scenario and identify the step of the nursing process
represented by each numbered and boldfaced nursing activity.
Annie seeks the help of the nurse in the student health clinic because she suspects
that her roommate, Angela, suffered date rape. She is concerned because Angela
chose not to report the rape and does not seem to be coping well. (1) After talking
with Annie, the nurse learns that although Angela blurted out that she had been raped
when she first came home, since then she has refused verbalization about the rape ("I
don't want to think or talk about it"), has stopped attending all college social activities
(a marked change in behavior), and seems to be having nightmares. After analyzing
the data, the nurse believes that Angela might be experiencing (2) rape-trauma
syndrome: silent reaction. Fortunately, Angela trusts Annie and is willing to come to
the student health center for help. A conversation with Angela confirms the nurse's
suspicions, and problem identification begins. The nurse talks further with Angela (3)
to develop some treatment goals and formulate outcomes. The nurse also begins to
think about the types of nursing interventions most likely to yield the desired
outcomes. In the initial meeting with Angela, (4) the nurse encourages her expression
of feelings and helps her to identify personal coping strategies and strengths. The
nurse and Angela decide to meet in 1 week (5) to assess her progress toward
achieving targeted outcomes. If she is not making progress, the plan of care might
need to be modified.
(1)
(2)
, (3)
(4)
(5)
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(1) is an illustration of assessing: the collection of patient data. (2) is an
illustration of the identification of a nursing diagnosis: a health problem that
independent nursing intervention can resolve.
(3) is an illustration of planning: outcome identification and related nursing
interventions. (4) is an illustration of implementing: carrying out the plan of
care.
(5) is an illustration of evaluating: measuring the extent to which Angela has
achieved targeted outcomes.
PHYSICAL ASSESSMENT/EXAM
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• Findings of physical examination (head to toe)
• Vital signs
• Labs, x-rays, diagnostic testing
• Interpreting assessment data will help to identify problem& establish the
nursing diagnoses
COMPLETE HEALTH HISTORY
Give this one a try later!
Give this one a try later!
, 1. communication
2. legal documentation
3. financial reimbursement
4. education/research
5. audit/monitoring
PRIORITIZE NURSING DIAGNOSIS
Give this one a try later!
Ex: Client s/p colon resection day 1
• Deficient knowledge
• Risk for ineffective airway clearance
• Nutrition less than body requirements
•Acute pain
1st - ineffective airway clearance
2nd - take care of pain
3rd -knowledge deficient
What does DAR mean?
Give this one a try later!
data, action, response
Implement
Give this one a try later!
, carry out the plan of care
What is PIE? and how is it different?
Give this one a try later!
Dx, interventions, evaluation; includes a nursing origin but not assessment
info
1. Read the following patient scenario and identify the step of the nursing process
represented by each numbered and boldfaced nursing activity.
Annie seeks the help of the nurse in the student health clinic because she suspects
that her roommate, Angela, suffered date rape. She is concerned because Angela
chose not to report the rape and does not seem to be coping well. (1) After talking
with Annie, the nurse learns that although Angela blurted out that she had been raped
when she first came home, since then she has refused verbalization about the rape ("I
don't want to think or talk about it"), has stopped attending all college social activities
(a marked change in behavior), and seems to be having nightmares. After analyzing
the data, the nurse believes that Angela might be experiencing (2) rape-trauma
syndrome: silent reaction. Fortunately, Angela trusts Annie and is willing to come to
the student health center for help. A conversation with Angela confirms the nurse's
suspicions, and problem identification begins. The nurse talks further with Angela (3)
to develop some treatment goals and formulate outcomes. The nurse also begins to
think about the types of nursing interventions most likely to yield the desired
outcomes. In the initial meeting with Angela, (4) the nurse encourages her expression
of feelings and helps her to identify personal coping strategies and strengths. The
nurse and Angela decide to meet in 1 week (5) to assess her progress toward
achieving targeted outcomes. If she is not making progress, the plan of care might
need to be modified.
(1)
(2)
, (3)
(4)
(5)
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(1) is an illustration of assessing: the collection of patient data. (2) is an
illustration of the identification of a nursing diagnosis: a health problem that
independent nursing intervention can resolve.
(3) is an illustration of planning: outcome identification and related nursing
interventions. (4) is an illustration of implementing: carrying out the plan of
care.
(5) is an illustration of evaluating: measuring the extent to which Angela has
achieved targeted outcomes.
PHYSICAL ASSESSMENT/EXAM
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• Findings of physical examination (head to toe)
• Vital signs
• Labs, x-rays, diagnostic testing
• Interpreting assessment data will help to identify problem& establish the
nursing diagnoses
COMPLETE HEALTH HISTORY
Give this one a try later!
