Chapter 5 For an in-depth study of documentation, consult the following publications: Balzer-Riley J: Communication in nursing: communicating assertively and responsibly in nursing, ed 7, St. Louis, 2012, Mosby. Nugent P, Green J, Hellmer Sau MA, Pelikan P: Mosby’s comprehensive review of nursing for the NCLEX-RN examination, ed 20, St. Louis, 2012, Mosby. Potter PA, Perry AG, Stockert PA, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. Assessment Data collection; tools used include patient and family interviews, functional areas, physical assessments, and laboratory tests; subjective aspects are those observed by patient; objective aspects are those observed by nurse Analysis Interpretation of collected patient data: determination of nursing diagnosis and plan of care; formation of nursing diagnoses Planning Formation of patient’s plan of care; patient goals are outcomes to be achieved by patient Implementation Nursing interventions; patient’s plan of care is based on assessments, analysis, and expected outcomes Evaluation Degree to which patient’s outcomes have been achieved; revision is an alteration in plan of care when expected outcomes are not achieved Patient centered Should reflect the patient behavior and responses to nursing interventions Singular Should address only one behavior or response Observable Must be able to observe if change takes place in a patient’s status Measurable Should measure the patient’s response to nursing care; terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely Time limited Time frames assist in determining if the patient is making progress and promote accountability in the delivery and management of nursing care Mutual Increases the patient’s motivation and cooperation Realistic Provide patients a sense of hope that increases motivation and cooperation Class 4: Cardiovascular/Pulmonary Responses Risk for Ineffective Gastrointestinal Perfusion Risk for Ineffective Renal Perfusion Impaired Spontaneous Ventilation Ineffective Peripheral Tissue Perfusion Risk for Decreased Cardiac Tissue Perfusion Risk for Ineffective Cerebral Tissue Perfusion Risk for Ineffective Peripheral Tissue Perfusion
Documentation
The Nursing Process
Documentation of Goals and Outcomes
Nursing Diagnoses by Functional Area
Domain 2: Nutrition
Domain 3: Elimination and Exchange
Domain 4: Activity/Rest
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