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PubMedDate not supplied

Functional health pattern assessment on-line. Lessons learned.

Assessment of patient care needs is the foundation for planning patient care and documenting the nursing process to enhance the nurse's ability to coordinate care, plan discharges effectively, and provide appropriate patient/family education. An on-line assessment module in the hospital clinical information system was implemented. This module uses Gordon's Functional Health Pattern Assessment as the foundation for the professional nursing documentation system in this academic, health science center. The article provides a description of the design of the pathways for the on-line assessment, analysis of the design, benefits of using the on-line assessment, and lessons learned from the design and implementation of the pathways.

Activities of Daily Living↗
PubMed2000

A perspective of nursing in Zimbabwe.

This article describes nursing in Zimbabwe within the context of primary health care, delineating various levels of delivery of nursing practice, educational preparation levels and implications for practice. This picture is intended to capture the quality of nursing care that is congruent to clients' expectations of the ever-changing Zimbabwean society. Nursing programs at various levels include health assessment, nursing process and nursing research. Clinical specialization including functional majors such as nursing education, nursing administration as well as health economics and budgeting have greater emphasis at the Masters level. The practice of nursing assists individuals, groups and communities to attain the ability to exercise their self-care to enhance health promotion.

Education, Nursing↗
PubMed2002

An assessment tool for the older person with spinal cord injury.

Normal aging changes intensify the chronic problems that are experienced by individuals with spinal cord injury (SCI). These changes place them at greater risk for developing vital systems failure and functional impairments, which if unrecognized, may lead to institutionalization or death. Understanding the trajectory of aging, and its impact on structure and function, is paramount in caring for individuals with SCI. Moreover, trends in health care toward capitation, managed care systems, and shifts to outpatient care portend a delivery system with more limited resources and greater restrictions (Lubitz, Greenberg, Gorina, Wartzman, & Gibson, 2001; National Institute of Aging, 2000). These trends potentially compromise health care access, quality, and cost for at-risk populations, especially for individuals aging with an SCI. Therefore, it behooves SCI nurses to develop a comprehensive approach to assess individuals who have chronic and debilitating injuries such as SCI. More importantly, assessing these individuals will require SCI nurses to adapt current tools that will aid in this endeavor and perhaps create new ones that will reflect the magnitude of SCI presentations and care. Employing the nursing process, SCI nurses will need to gather data from a myriad of sources. The first important step is establishing a baseline. Using a functional health pattern tool (FHPT) developed by Gordon (1987), and adapted from the North American Nursing Diagnosis Association (1987), is one such method of constructing a database and formulating diagnoses (Gordon, 1994). The FHPT provides a holistic view of individuals and families in any practice setting and it can be easily adapted to specialty areas within nursing. Therefore its application to both SCI and aging is fitting (Popkess-Vawter, 1997). These authors adapted the FHPT format to create a tool that will make it more reflective of changes that occur in individuals who have SCI and are aging.

Aged↗
PubMedDate not supplied

Outpatient management of low back pain.

Low back pain affects 80% of adults some time in their lives. It is expensive, costing more than $16 billion per year, and causes 40-50% of all lost work days. A variety of disorders can cause low back pain, but the majority of time the problem is self-limiting and resolves within a few weeks. There are specific risk factors associated with low back pain, temporary measures that can be helpful to decrease discomfort, and specific ways to prevent future episodes. The most important management modality is education, and most patients are treated in the outpatient setting. Nursing care is frequently provided by telephone. Using the nursing process, the nurse can assess and advise patients in a systematic, timely manner while maintaining a nursing focus.

Ambulatory Care↗
PubMed1997

[The diagnostic process in nursing].

The aim of this investigation was to uncover the reason of difficulties nurses have in defining the patient's problem. For this reason the diagnostic process of nurses caring for patients in pain was investigated in the field. Observations, interviews and questionnaires were analysed in a qualitative and quantitative way. The analysis of the data shows that the observed nurses didn't value the information received by using the problem solving process and didn't use it to define the nursing problem. But the results also point out that nurses have the ability to gather information in the direct contact with the patient. The question is: could there be a lack of training in cognitive processes?

Cognition↗
PubMed2005

Nursing outcome documentation in nursing notes of cardiac-surgery patients.

This study analyzed what nurses wrote in narrative nursing notes for nursing outcome of cardiac-surgery patients. The nursing notes of 46 patients were decomposed into phrases and analyzed based on the nursing process. Eight patterns were extracted according to different combinations of nursing-process components, of which 29.2% have nursing outcome phrases. The content of the nursing notes was also classified into 15 categories, of which nursing outcomes were recorded more frequently in nursing care driven mainly by physician's order, such as disease-related symptom management, insomnia care, respiratory care, and pain control, than in independent nursing care such as education and emotional care. A survey on the attitudes of nurses toward the nursing record revealed that they do not document nursing outcomes as much as they think they do. The main reasons for this discrepancy were insufficient time for recording and lack of knowledge about why, how, and what to evaluate. Even though there is room for improvement, nursing notes represent a useful resource for determining nursing contributions to patient outcomes.

Cardiac Surgical Procedures↗
PubMed2003

Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district.

The aim of this study was to investigate the adherence of nursing documentation to clinical guidelines in leg ulcer patients. Using two audit instruments, 100 patient records from primary health care were reviewed. The nursing content in the records was assessed according to instructions for documentation in local clinical guidelines for leg ulcers and the comprehensiveness of the nursing process in recording was reviewed. The results indicated deficiencies in the documentation of aspects of relevance in the care of leg ulcer patients. In addition, the findings indicated flaws in the adoption of the nursing process in recording. Only one problem in one patient record was recorded that consistently used the nursing process. The conclusion is that, despite specific and locally developed guidelines for care of leg ulcer patients, nursing records did not provide a precise audit of the care process. Because patient record information without a clear structure following the nursing process tends to impede communication and evaluation of care, such defective information is likely to have a significant impact on the continuity and quality in patient care.

Adult↗
PubMed1989

Effects of a geriatric nurse practitioner on process and outcome of nursing home care.

We compared measures of quality of care and health services utilization in 30 nursing homes employing geriatric nurse practitioners with those in 30 matched control homes. Information for this analysis came from reviews of samples of patient records drawn at comparable periods before and after the geriatric NPs were employed. The measures of geriatric nurse practitioner impact were based on comparisons of changes from pre-NP to post-NP periods. Separate analyses were done for newly admitted and long-stay residents; a subgroup of homes judged to be best case examples was analyzed separately as well as the whole sample. Favorable changes were seen in two out of eight activity of daily living (ADL) measures: five of 18 nursing therapies; two of six drug therapies; six of eight tracers. There was some reduction in hospital admissions and total days in geriatric NP homes. Overall measures of medical attention showed a mixed pattern with some evidence of geriatric NP care substituted for physician care. These findings suggest that the geriatric NP has a useful role in nursing home care.

Activities of Daily Living↗
PubMedDate not supplied

Factors affecting and affected by user acceptance of computer-based nursing documentation: results of a two-year study.

OBJECTIVES: The documentation of the nursing process is an important but often neglected part of clinical documentation. Paper-based systems have been introduced to support nursing process documentation. Frequently, however, problems such as low quality of documentation are reported. It is unclear whether computer-based documentation systems can reduce these problems and which factors influence their acceptance by users. DESIGN: We introduced a computer-based nursing documentation system on four wards of the University Hospitals of Heidelberg and systematically evaluated its preconditions and its effects in a pretest-posttest intervention study. For the analysis of user acceptance, we concentrated on subjective data drawn from questionnaires and interviews. MEASUREMENTS: A questionnaire was developed using items from published questionnaires and items that had to be developed for the special purpose of this study. RESULTS: The quantitative results point to two factors influencing the acceptance of a new computer-based documentation system: the previous acceptance of the nursing process and the previous amount of self-confidence when using computers. On one ward, the diverse acceptance scores heavily declined after the introduction of the nursing documentation system. Explorative qualitative analysis on this ward points to further success factors of computer-based nursing documentation systems. CONCLUSION: Our results can be used to assist the planning and introduction of computer-based nursing documentation systems. They demonstrate the importance of computer experience and acceptance of the nursing process on a ward but also point to other factors such as the fit between nursing workflow and the functionality of a nursing documentation system.

Attitude of Health Personnel↗
PubMed2005

Examining nurses' decision process for medication management in home care.

BACKGROUND: The process of medication management within home care agencies was prospectively described, with a focus on the nurse's role and critical points in the process. The process the nurse must follow includes preparing, checking, and administering medications; updating knowledge of medications; monitoring the effectiveness of treatment; reporting adverse reactions; and teaching patients about their drugs. PROCESSES FOR MEDICATION MANAGEMENT IN HOME HEALTH CARE: The steps that home health nurses (HHNs) go through with families and the system changes that could be developed to decrease errors were identified. The approach was based on Failure Mode and Effects Analysis-a method to identify and prevent process problems before they occur. The medication management process was divided into drug utilization review (DUR) for duplicative and harmful interactions; drug administration by the patient, family member, and/or caregiver; and side effects. Failure modes were developed for a DUR for duplicative and harmful interactions. DISCUSSION: Home health agencies should analyze the medication management process in their own agencies and identify system solutions. The difficulty encountered by HHNs in contacting physicians to discuss changes to the drug regimen following the assessment of potential drug interactions or duplications is an ongoing problem. Careful monitoring by HHNs could decrease the impact of adverse drug effects.

Decision Making↗
PubMedDate not supplied

Reaching collaboration through empowerment: a developmental process.

Nurses are well positioned to play an influential role in health care reform. As the concept of collaboration takes on new meanings, nurses must be prepared to function in interdisciplinary groups. They need to move from a unidisciplinary model of problem solving through a nursing approach to a multidisciplinary model, where different professions work as equal members of a team. The ultimate goal is to reach an interdisciplinary model in which team members from a variety of disciplines modify their perspective in light of other perspectives. Empowerment is viewed as an individual developmental process that occurs in stages during a period of time. Nurses will be better able to collaborate in an egalitarian manner once they have personally become empowered. It is up to nursing to seize the opportunity to become an equal partner in today's health care.

Cooperative Behavior↗
PubMedDate not supplied

Implementation of nursing conceptual models: observations of a multi-site research team.

The general acceptance by nursing of the nursing process as the methodology of practice enabled nurses to have a common grounding for practice, research and theory development in the 1970s. It has become clear, however, that the nursing process is just that--a process. What is sorely needed is the nursing content for that process and consequently in the past 10 years nursing theorists have further developed their particular conceptual models (CM). Three major teaching hospitals in Toronto have instituted a conceptual model (CM) of nursing as a basis of nursing practice. Mount Sinai Hospital has adopted Roy's adaptation model; Sunnybrook Medical Centre, Kings's goal attainment model; and Toronto General Hospital, Orem's self-care deficit theory model. All of these hospitals are affiliated through a series of cross appointments with the Faculty of Nursing at the University of Toronto. Two community hospitals, Mississauga and Scarborough General, have also adopted Orem's model and are related to the University through educational, community and interest groups. A group of researchers from these hospitals and the University of Toronto have proposed a collaborative project to determine what impact using a conceptual model will make on nursing practice. Discussions among the participants of this research group indicate that there are observations associated with instituting conceptual models that can be identified early in the process of implementation. These observations may be of assistance to others contemplating the implementation of conceptually based practice in their institution.

Attitude of Health Personnel↗