Standard 1: Assessment
The registered nurse collects comprehensive data pertinent to the healthcare consumer’s health and/or the situation (ANA, 2010a, p.32).
Description and Comparison
The nurse performs the head to toe assessment technique, as well as focused assessments in emergent situations. The RN systematically assesses a patient’s needs, readiness to learn, barriers (communication, educational level, emotional, and physical limitations) that affect learning, religious/cultural beliefs, medication and health history, and risk for falls. The assessment tools include the Braden Scale for pressure ulcer prevention, the Faces Pain Rating Scale, and the Johns Hopkins Fall Risk ...view middle of the document...
Examples of barriers: nurses do not review recent narcotic medications given, workplace distractions, and time constraints. Patients’ with dementia or sundowners have a lack of knowledge due to their memory loss, which causes them to get out of bed without assistance. Physicians order two or four point restraints when needed for patients with dementia, physiological disorders, and combative patients.
One of Sentara’s core values is “Safety Trumps privacy”. An example is the patient’s fall risk assessment that categorizes him/her as a high risk for falls. High fall risk patients need assistance to the restroom and staff must remain with that patient until he/she is safely back in bed. This does not always happen due to call bells continuously ringing, shortage of staff, and occurrences of emergent situations.
The benefits of the eCare system: real-time documentation, improved communication and collaboration between disciplines, easily accessible from any location, stores past medical history, and reduces occurrences of errors. The eCare system is an essential component for patient care and eliminates the use of paper. If the system crashed, it would cause a halt in patient care because the staff is not knowledgeable about paper charting.
Standard 2: Diagnosis
The registered nurse analyzes the assessment data to determine the diagnosis or the issues (ANA, 2010a, p.34).
Description and Comparison
After the assessment, the nurse is knowledgeable in regards to the patient’s educational level, ability to learn new information, willingness to apply recently gained knowledge, dietary habits, social habits, updated medication list, medical history, and functional ability with activities of daily living (ADL). After performing the assessment, the RN evaluates the data with a systematic approach using a chronological analysis technique. This technique aids in identifying actual or potential health risks/concerns for the patient. After identification of health risks, the nurse uses her own evidence-based knowledge and experience in formulating patient centered diagnoses. The nurse documents these diagnoses as part of the patient care plan within the patient’s EMR.
Critique and Analysis
There are barriers to the diagnosis standard of practice. Nurses have to use their judgment, experience, and current knowledge to analyze the assessment data in order to formulate quality care diagnoses. All people view things from different perspectives which can create inconsistency in proper diagnosing of a patient and impacts their outcomes. Although Sentara has set policies regarding documentation of diagnosis within the patient care plan, many nurses fail to address the care plan. Sentara is currently instituting new policies for non-compliance in charting care plans.
Standard 3: Outcome Identification
The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation (ANA, 2010a,...