- Email: [email protected]
Development of a Perioperative Nursing Diagnoses Flow Sheet
MARCH 1995, VOL 61, NO 3 Null * Ric,hter.-Aht Kovac
Development of a Perioperative Nursing Diagnoses Flow Sheet he idea of creating a flow sheet to document perioperative nursing care at DePaul Health Center, St Louis, began in the spring of 1991. The center’s preoperative and postoperative units recognized that documentation tools lacked both nursing diagnosis terminology and the ability to document the related nursing interventions. The manager of outpatient surgery reviewed the existing perioperative record and noted that certain observations, nursing diagnoses, and interventions were relevant to all phases of perioperative care. After discussing these observations with the surgical services director, the outpatient surgery manager decided to form a nursing diagnosis task force (NDTF). The task force was charged with investigating the feasibility of a flow sheet that would encompass all phases of perioperative care. This flow sheet would identify the most common nursing diagnoses relevant to perioperative patients, document interventions throughout the perioperative course, and
allow other professionals to review the nursing diagnoses addressed during perioperative phases, thus providing continuity of care. The nurse manager of each phase of care reviewed the NDTF goals and recommended potential task force members. Task force members were chosen from this group on the basis of their past involvement in other projects and their comniitment to quality in patient care. The NDTF, chaired by the outpatient nurse manager and composed entirely of professional registered nurses, consisted of the preadmission testing (PAT) coordinator, the surgical services clinical nurse specialist, two nurses from outpatient surgery, two from the OR, one from the postanesthesia care unit (PACU), and one from the gastrointestinal endoscopy unit. STARTING TllE PROCESS
The NDTF met for the first time in July 1991 to formulate objectives and discuss an overview of nursing diagnoses in perioperative care. The task force members agreed to pursue the development of a flow sheet B S T R A C T that identified nursing diagnoses Traditionally, health care professionals in the preoperative, and interventions throughout periintraoperative, and postoperative phases of care have used periop- operative care. This documentaerative records that focus on the technical aspects of the care pro- tion tool would use nursing diagnosis termivided (eg, blood pressure, pulse measurements; equipment used) nology to document perioperand leave room for only short narratives to document nursing care. ative nursing care and pracSuch formats often do not document the multitude of activities or tice; interventions perioperative nurses provide. The question raised at promote and provide continuthe DePaul Health Center, St Louis, was: “Where do we document ity in care and documentation our nursing diagnoses and plan of care?” The response was to crein all phases of perioperative ate a nursing diagnosis task force that investigated the feasibility of nursing; a form professional nurses could use in all phases of patient care. encourage acceptance, as a This investigation led to the development, implementation, and unipeer group, of each professionversal use of a perioperative nursing diagnoses flow sheet within the al nurse’s practice; surgical services department. AORN J61 (March 95) 547-557.
547 AORN JOURNAL
-
MARCH 1995,VOL 61, NO 3 Null h’ic,hnr--Aht Km~ac,
The flow sheet amtains 11 nursingdiagnseschosenbecaweof the pmbability of occurrencein
perioperativepatients.
promote efficient use of documentation time and elimination of repetitive documentation; meet Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards NC. 1.3-NC. 1.3.4.6’ provide continuing education for staff members in nursing diagnosis terminology and documentation of the nursing process; and describe professional perioperative nursing practice.
and in the end, the task force members decided to produce a trifold perioperative nursing diagnoses flow sheet that could be inserted easily into a patient’s permanent record and follow the patient through the perioperative experience. Eight months into the flow sheet development process, the NDTF members each chose peers to attend a flow sheet review meeting. The task force members believed an impartial peer group was needed to evaluate the flow sheet and make recommendations. The peer group studied the draft for two weeks before making its recommendations for changes in both content and format. Overall, the peer group members gave the perioperative nursing diagnoses flow sheet positive and supportive evaluations, although they discussed the negative aspects of having another form to complete. The NDTF then went back to work to execute some of the changes discussed with the peer group. One recommendation implemented was to remove the narrative notes from each page and combine them in one large section at the end of the flow sheet. As editing continued, the task force members investigated ways to make the flow sheet more user-friendly.
DMLOPING THE FLOW SHE-
The NDTF met biweekly for one hour each time and made assignments based on members’ areas of expertise. The clinical nurse specialist served as the resource for nursing diagnosis terminology and nursing process. Each NDTF member determined nursing diagnoses for a specific perioperative population. The diagnoses chosen were based on the probability of occurrence in their perioperative area. All diagnoses identified and used in the development of the periopcrativc nursing diagnoses flow sheet were from the North American Nursing Diagnosis Association-approved nursing diagnoses list.2 The NDTF worked for one year on developing the documentation form. After the nursing diagnoses were chosen, the task force members identified and listed interventions and created a format conducive to information flow among several perioperative areas. The project objectives remained essentially the same throughout the year, but the scope of the flow sheet grew with each step of development. The NDTF then began editing the flow sheet to a workable size, which was not always easy because members lobbied for interventions particular to their areas. Creating the form’s format took many hours,
USING THE FLOW SHEET
The flow sheet contains the 11 nursing diagnoses chosen by the NDTF and contains the phrase “related to,” which is denoted by the abbreviation R/r. 0 Potential knowledge deficit R/T unknown; the environment and surgical procedure Potential alteration in family and individual coping mechanisms R,T anxiety, fear, and/or inadequate support systems 0 Potential for infection R/T surgical procedure, foreign environment 0 Potential alterations in ventilation and cardiovascular function R E anesthesia with surgical procedure Potential alterations in fluid/electrolyte balance R/T surgical procedure, blood loss, and NPO status Alterations in integumentary system R/T surgical procedures 0 Potential for impaired mobility/physical injury R/T anesthesia/sedat ion/surgical procedure 0 Alterations in level of consciousness R/T anesthetic agents Alterations in comfort R/T anxiety, disease pathology, and effects of surgical procedure 0 Potential for noncompliance R/T comprehension of instructions and/or explanations 9
9
548 AORN JOlJRNAL
Figure 1 Page one of the perioperative nursing diagnoses flow sheet used at DePaul Health Center, St Louis. This page shows diagnoses one through three and the corresponding perioperative nursing interventions.
Figure 2 Page two of the perioperative nursing diagnoses flow sheet used at DePaul Health Center, St Louis, shows diagnoses four and five and the corresponding perioperative nursing interventions.
550 .\OR\ IOUKIUAL
MARCH 1995. VOL 61. NO 3 Null Ric,hrer--Aht * K o i w
The specific interventions on the flow chart were drawn from all phases of patient care.
Potential for self-care deficit, with impaired home management, R/T altered mobility and/or activity tolerance Of these diagnoses, only those found on the first two pages of the flow sheet are shown in Figures 1 and 2. T h e common defining characteristic is that the patient is undergoing a diagnostic or therapeutic invasive procedure. The diagnoses, desired outcomes, and potential nursing interventions are listed to facilitate documentation by the RNs. Additional nursing diagnoses may be addressed in the space provided (Figure 3). All 11 identified diagnoses may or may not apply to each patient. The perioperative nursing diagnoses flow sheet is initiated by an RN in the surgical services department at the time of the patient’s admission. Areas of admission may include a preadmission testing visit before the day of surgery, admission to outpatient surgery unit on the day of surgery, or admission to the OR as an inpatient or as an emergency directadmit patient. Information obtained and documented on the flow sheet at the time of admission is available in each subsequent perioperative phase a s the patient progresses through his or her surgical experience. The perioperative nursing diagnoses flow sheet includes care identified in the following phases. Preadmission testing (PAT): The- patient is in preadmission testing before the day of surgery. Preoperative (PRE-OP): The patient is based in the outpatient surgery unit for preoperative preparation the day of surgery. Intraoperative (INTRA-OP): The patient’s surgery is based in the OR. P A C U I: T h e patient i \ in the PACU and is admitted to the health center or returned to outpatient surgery.
PACU 11. The patient is in the secondary PACU and discharge unit, which is based in the outpatient surgery area. If a patient bypasses a phase of care, that phase remains blank. An example would be a patient who does not participate in the preadmission testing program. This patient‘s first contact, and therefore the first entry on the flow sheet, would be in the preoperative phase of care. The RN representing a particular perioperative phase addresses and dates (where requested) each diagnosis, assessment statement, and desired outcome; identifies pertinent diagnoses according to the legend; and initials the flow sheet. The pertinent diagnoses are identified by the following legend. Ongoing (0):The need continues to exist and requires further interventions for resolution. Ongoing, no intervention (O/N): The need continues to exist but no interventions are appropriate in this area or at this time. Resolved (R): The patient has achieved the desired outcome through nursing intervention. Not applicable ( N / A ) : T h e patient has been assessed. and the particular need is not identified. Nurses must identify interventions implemented for each identified diagnosis. The specific interventions listed on the flow chart were drawn from all phases of patient care and, therefore, may or may not apply to a patient at the perioperative phase being addressed. The RN identifies implemented intervention by initialing the appropriate space on the form. The interventions not applicable to the patient or the perioperative phase remain blank. The perioperative nursing diagnoses flow sheet reduces the number of narrative notes recorded while it increases the amount of information available about the patient’s needs and the perioperative nursing interventions completed to meet those needs. The flow sheet does contain an area for necessary narrative documentation. The first diagnosis listed asks for a patient quote regarding his or her knowledge of the proposed procedure. In striving to individualize patient care, the patient quote has proven very useful. By using this quotation approach. nurses have identified patients who need additional support or information and have avoided miscommunication and possible delays in care. After completing the documentation, the RN initials and signs the signature block at the end of the flow sheet. 552
AORN JOURh A L
Figure 3 The last page of the perioperative nursing diagnoses flow sheet used at DePaul Health Center, St Louis, has room for additional nursing documentation and signatures.
MARCH 1995, VOL 6 1, NO 3 Null
Hii
Irtri - A h
Koiw
PILOT PROGRAM
IMPLEMENTATION
After the NDTF members worked on the flow sheet development project for one year, they initiated a pilot program. They chose neurosurgical patients for the pilot program because these patients were a small percentage of total health center surgical volume, exposed to all phases of perioperative care, and a mix of inpatient and outpatient populations. One NDTF member and staff nurses from each phase of perioperative care participated in the pilot program. The staff nurses who participated in the pilot program attended a two-hour education session, reviewed the flow sheet objectives and instructions, and practiced with the flow sheet using different patient scenarios. The NDTF maintained control of patient selection for the pilot program by following this process. The PAT coordinator identified patients scheduled for neurosurgery procedures. The PAT coordinator provided the outpatient nurse manager with a list of patients. The outpatient nurse manager assigned a pilot program staff nurse to care for the patient in the pretesting, preoperative, and PACU I1 phases of care. The neurosurgical OR team members reviewed the surgery schedule daily and prepared for participating clients. An NDTF member from PACU I reviewed the daily surgery schedule and notified the PACU manager of any pilot patients who would be in the PACU. The PACU manager made staffing assignments accordingly. This system was successful in capturing the majority of patients who were eligible for the pilot program. The perioperative nursing diagnoses flow sheets being pilot tested were not placed in the patients’ charts on a permanent basis because the flow sheets had not received final approval by the medical records department. The pilot project group and NDTF members met to review the completed flow sheets after the one-month pilot program period. The NDTF spent an additional two months making suggested content and format changes to improve and condense the flow sheet material. The NDTF submitted the final perioperative nursing diagnoses flow sheet for approval by the nursing practice council in accordance with nursing departmental policy. The perioperative nursing diagnoses flow sheet then went to the medical records form committee for final approval, which was received in January 1993.
After the pilot program and multiple revisions were completed and approvals received, the NDTF was ready to use the flow sheet throughout the perioperative area. The next challenge was to educate more than 50 RNs about the flow sheet process and meet the anticipated resistance to change. Each staff nurse on the NDTF was responsible for educating his or her own department. Each nurse used the same teaching method but was able to satisfy the specific needs and requirements of his or her department. The task force members’ goal was to educate all staff nurses in one month. Each educator limited the inservice sessions to one and one-half hours in length with three to six staff nurses in attendance per session. To maintain consistency, the nurse educator used an overhead projection of each nursing diagnosis to demonstrate flow sheet documentation. Step one of the education process included a general overview of the perioperative nursing diagnoses flow sheet with its philosophy, goals, and objectives. Next, each nursing diagnosis was addressed with a scenario depicting primary examples relevant to a typical patient i n the specific department. This approach created an atmosphere in which additional department-specific questions could be raised and addressed. The NDTF believed that a small number of employees in each group would promote a stronger understanding of the flow sheet and allow the educator to give staff nurses individualized attention. Each education session was productive because the educator held expertise in both the flow sheet development and in the nursing care provided by the specific department. The initial education process was completed one and one-half weeks before the preestablished one-month goal. The education sessions quickly resolved staff members’ initial fears regarding the flow sheet. The NDTF wasted no time implementing the flow sheet as a pennanent part of patients’ charts. The learning process continued through the first few weeks of implementation. Staff nurses in the PACU provided important input in the continued learning process because they were able to review flow sheets with three phases of care already completed. When questionable or incorrect documentation occurred, the PACU nurses alerted their task force member. With this timely information, the primary NDTF members could address questions and errors within their own departments. 554
AORN JOURNAL
MARCH 1995, VOL 61, NO 3 - N u / / Richter-Aht Kovac
CONCLUSION
The NDTF created and implemented a documentation tool that combines nursing diagnoses and includes all phases of perioperative nursing care. The perioperative nursing diagnoses flow sheet is easy to complete and uses documentation time more efficiently. Also, the flow sheet meets the JCAHO nursing standards that relate to nursing diagnosis documentation. Constructing and implementing the perioperative nursing diagnoses flow sheet was time-consuming and required each department to review and change records that the flow sheet might duplicate. As with any change, there remains some resistance to the use of the flow sheet; however, most perioperative staff members have learned to use the flow sheet and integrate it into their practices with little NOTES 1. Joint Commission on Accreditation of Healthcare Organizations, “Nursing Care,” in 1993Joint Com-
difficulty. The perioperative nursing diagnoses flow sheet, as with all perioperative documentation tools, will be periodically reviewed and revised. A Sandra Null, RN, is coordinator of preadmission testing and surgery at DePaul Health Center, St Louis. Diane Richter-Abt, RN, BS, is a postanesthia care unit stajjf nurse at DePaul Health Center, St Louis. Jane Kovac, RN, is employment supeivisorlnurse recruiter at DePaul Health Center, St Louis. The authors would like to thank the other nursing diagnosis task force members, Sue Denningman, RN, and Linda Franklyn, RN,for their efforts and support.
mission Accreditation Munual for Hospitals (Oakbrook Terrace, 111: Joint Commission on Accreditation of Healthcare Organizations, 1992) 79-80.
2. L J Carpenito,Nursing D i q nosis Application to Clinical Practice, fourth ed (Philadelphia:J B Lippincott Co, 1992) 7-9.
Lacing Shoes Properly Can Prevent Foot Problems Women are discovering that the way they lace their shoes can make shoes fit better and also can prevent foot problems later in life. Because most women’s athletic shoes are scaled-down versions of men’s shoes, they do not fit women’s feet appropriately. Learning certain lacing techniques can improve the fit of many of these shoes, according to an Oct 1 1, 1994, press release from the American Academy of Orthopaedic Surgeons. Shoes with a large number of eyelets offer the most lacing options and allow the best custom fit, the release states. Women with narrow feet should use the eyelets farthest from the tongue of the shoe. This technique brings the sides of the shoe up higher and helps them fit tightly across the top of the foot. Women with wide feet should use only the eyelets closest to the tongue to allow the most space within the shoe-like letting out a corset, according to the article. Women often have problems finding athletic shoes that fit their heels properly because many shoes have heels that are too big for women’s feet. To prevent heel pain and blisters, the release states, every eyelet on the shoe should be used. At the next
to last eyelet on each side, the lace should be threaded through the top eyelet rather than crossing over to the eyelet on the opposite side. This forms a small loop, through which the opposite lace should be threaded before tying the laces. The area closest to the heel (ie, the top of the shoe) should be tied the tightest; less tension should be used toward the toes, the release states. Women who choose smaller shoes to ensure a proper fit in the heel often have foot deformity and pain as a result of shoes that are too tight in the forefoot area. The release states that 73% of women chose shoes for the heel fit and experienced foot pain as a result. In addition to learning lacing techniques, women also should try shoes on at the end of the day when their feet are the largest and make sure the forefoot is not crowded in the shoe (ie, make sure that toes can extend). According to the release, the shoe should be 1/2 inch longer than the longest toe. Lacing Techniques Make Women’s Shoes Fit Better (news release, Rosemonf, 111: American Academy of Otfhapaedic Surgeons, Oct 1 1, 1994).
557 AORN JOURNAL
Development of a Perioperative Nursing Diagnoses Flow Sheet he idea of creating a flow sheet to document perioperative nursing care at DePaul Health Center, St Louis, began in the spring of 1991. The center’s preoperative and postoperative units recognized that documentation tools lacked both nursing diagnosis terminology and the ability to document the related nursing interventions. The manager of outpatient surgery reviewed the existing perioperative record and noted that certain observations, nursing diagnoses, and interventions were relevant to all phases of perioperative care. After discussing these observations with the surgical services director, the outpatient surgery manager decided to form a nursing diagnosis task force (NDTF). The task force was charged with investigating the feasibility of a flow sheet that would encompass all phases of perioperative care. This flow sheet would identify the most common nursing diagnoses relevant to perioperative patients, document interventions throughout the perioperative course, and
allow other professionals to review the nursing diagnoses addressed during perioperative phases, thus providing continuity of care. The nurse manager of each phase of care reviewed the NDTF goals and recommended potential task force members. Task force members were chosen from this group on the basis of their past involvement in other projects and their comniitment to quality in patient care. The NDTF, chaired by the outpatient nurse manager and composed entirely of professional registered nurses, consisted of the preadmission testing (PAT) coordinator, the surgical services clinical nurse specialist, two nurses from outpatient surgery, two from the OR, one from the postanesthesia care unit (PACU), and one from the gastrointestinal endoscopy unit. STARTING TllE PROCESS
The NDTF met for the first time in July 1991 to formulate objectives and discuss an overview of nursing diagnoses in perioperative care. The task force members agreed to pursue the development of a flow sheet B S T R A C T that identified nursing diagnoses Traditionally, health care professionals in the preoperative, and interventions throughout periintraoperative, and postoperative phases of care have used periop- operative care. This documentaerative records that focus on the technical aspects of the care pro- tion tool would use nursing diagnosis termivided (eg, blood pressure, pulse measurements; equipment used) nology to document perioperand leave room for only short narratives to document nursing care. ative nursing care and pracSuch formats often do not document the multitude of activities or tice; interventions perioperative nurses provide. The question raised at promote and provide continuthe DePaul Health Center, St Louis, was: “Where do we document ity in care and documentation our nursing diagnoses and plan of care?” The response was to crein all phases of perioperative ate a nursing diagnosis task force that investigated the feasibility of nursing; a form professional nurses could use in all phases of patient care. encourage acceptance, as a This investigation led to the development, implementation, and unipeer group, of each professionversal use of a perioperative nursing diagnoses flow sheet within the al nurse’s practice; surgical services department. AORN J61 (March 95) 547-557.
547 AORN JOURNAL
-
MARCH 1995,VOL 61, NO 3 Null h’ic,hnr--Aht Km~ac,
The flow sheet amtains 11 nursingdiagnseschosenbecaweof the pmbability of occurrencein
perioperativepatients.
promote efficient use of documentation time and elimination of repetitive documentation; meet Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards NC. 1.3-NC. 1.3.4.6’ provide continuing education for staff members in nursing diagnosis terminology and documentation of the nursing process; and describe professional perioperative nursing practice.
and in the end, the task force members decided to produce a trifold perioperative nursing diagnoses flow sheet that could be inserted easily into a patient’s permanent record and follow the patient through the perioperative experience. Eight months into the flow sheet development process, the NDTF members each chose peers to attend a flow sheet review meeting. The task force members believed an impartial peer group was needed to evaluate the flow sheet and make recommendations. The peer group studied the draft for two weeks before making its recommendations for changes in both content and format. Overall, the peer group members gave the perioperative nursing diagnoses flow sheet positive and supportive evaluations, although they discussed the negative aspects of having another form to complete. The NDTF then went back to work to execute some of the changes discussed with the peer group. One recommendation implemented was to remove the narrative notes from each page and combine them in one large section at the end of the flow sheet. As editing continued, the task force members investigated ways to make the flow sheet more user-friendly.
DMLOPING THE FLOW SHE-
The NDTF met biweekly for one hour each time and made assignments based on members’ areas of expertise. The clinical nurse specialist served as the resource for nursing diagnosis terminology and nursing process. Each NDTF member determined nursing diagnoses for a specific perioperative population. The diagnoses chosen were based on the probability of occurrence in their perioperative area. All diagnoses identified and used in the development of the periopcrativc nursing diagnoses flow sheet were from the North American Nursing Diagnosis Association-approved nursing diagnoses list.2 The NDTF worked for one year on developing the documentation form. After the nursing diagnoses were chosen, the task force members identified and listed interventions and created a format conducive to information flow among several perioperative areas. The project objectives remained essentially the same throughout the year, but the scope of the flow sheet grew with each step of development. The NDTF then began editing the flow sheet to a workable size, which was not always easy because members lobbied for interventions particular to their areas. Creating the form’s format took many hours,
USING THE FLOW SHEET
The flow sheet contains the 11 nursing diagnoses chosen by the NDTF and contains the phrase “related to,” which is denoted by the abbreviation R/r. 0 Potential knowledge deficit R/T unknown; the environment and surgical procedure Potential alteration in family and individual coping mechanisms R,T anxiety, fear, and/or inadequate support systems 0 Potential for infection R/T surgical procedure, foreign environment 0 Potential alterations in ventilation and cardiovascular function R E anesthesia with surgical procedure Potential alterations in fluid/electrolyte balance R/T surgical procedure, blood loss, and NPO status Alterations in integumentary system R/T surgical procedures 0 Potential for impaired mobility/physical injury R/T anesthesia/sedat ion/surgical procedure 0 Alterations in level of consciousness R/T anesthetic agents Alterations in comfort R/T anxiety, disease pathology, and effects of surgical procedure 0 Potential for noncompliance R/T comprehension of instructions and/or explanations 9
9
548 AORN JOlJRNAL
Figure 1 Page one of the perioperative nursing diagnoses flow sheet used at DePaul Health Center, St Louis. This page shows diagnoses one through three and the corresponding perioperative nursing interventions.
Figure 2 Page two of the perioperative nursing diagnoses flow sheet used at DePaul Health Center, St Louis, shows diagnoses four and five and the corresponding perioperative nursing interventions.
550 .\OR\ IOUKIUAL
MARCH 1995. VOL 61. NO 3 Null Ric,hrer--Aht * K o i w
The specific interventions on the flow chart were drawn from all phases of patient care.
Potential for self-care deficit, with impaired home management, R/T altered mobility and/or activity tolerance Of these diagnoses, only those found on the first two pages of the flow sheet are shown in Figures 1 and 2. T h e common defining characteristic is that the patient is undergoing a diagnostic or therapeutic invasive procedure. The diagnoses, desired outcomes, and potential nursing interventions are listed to facilitate documentation by the RNs. Additional nursing diagnoses may be addressed in the space provided (Figure 3). All 11 identified diagnoses may or may not apply to each patient. The perioperative nursing diagnoses flow sheet is initiated by an RN in the surgical services department at the time of the patient’s admission. Areas of admission may include a preadmission testing visit before the day of surgery, admission to outpatient surgery unit on the day of surgery, or admission to the OR as an inpatient or as an emergency directadmit patient. Information obtained and documented on the flow sheet at the time of admission is available in each subsequent perioperative phase a s the patient progresses through his or her surgical experience. The perioperative nursing diagnoses flow sheet includes care identified in the following phases. Preadmission testing (PAT): The- patient is in preadmission testing before the day of surgery. Preoperative (PRE-OP): The patient is based in the outpatient surgery unit for preoperative preparation the day of surgery. Intraoperative (INTRA-OP): The patient’s surgery is based in the OR. P A C U I: T h e patient i \ in the PACU and is admitted to the health center or returned to outpatient surgery.
PACU 11. The patient is in the secondary PACU and discharge unit, which is based in the outpatient surgery area. If a patient bypasses a phase of care, that phase remains blank. An example would be a patient who does not participate in the preadmission testing program. This patient‘s first contact, and therefore the first entry on the flow sheet, would be in the preoperative phase of care. The RN representing a particular perioperative phase addresses and dates (where requested) each diagnosis, assessment statement, and desired outcome; identifies pertinent diagnoses according to the legend; and initials the flow sheet. The pertinent diagnoses are identified by the following legend. Ongoing (0):The need continues to exist and requires further interventions for resolution. Ongoing, no intervention (O/N): The need continues to exist but no interventions are appropriate in this area or at this time. Resolved (R): The patient has achieved the desired outcome through nursing intervention. Not applicable ( N / A ) : T h e patient has been assessed. and the particular need is not identified. Nurses must identify interventions implemented for each identified diagnosis. The specific interventions listed on the flow chart were drawn from all phases of patient care and, therefore, may or may not apply to a patient at the perioperative phase being addressed. The RN identifies implemented intervention by initialing the appropriate space on the form. The interventions not applicable to the patient or the perioperative phase remain blank. The perioperative nursing diagnoses flow sheet reduces the number of narrative notes recorded while it increases the amount of information available about the patient’s needs and the perioperative nursing interventions completed to meet those needs. The flow sheet does contain an area for necessary narrative documentation. The first diagnosis listed asks for a patient quote regarding his or her knowledge of the proposed procedure. In striving to individualize patient care, the patient quote has proven very useful. By using this quotation approach. nurses have identified patients who need additional support or information and have avoided miscommunication and possible delays in care. After completing the documentation, the RN initials and signs the signature block at the end of the flow sheet. 552
AORN JOURh A L
Figure 3 The last page of the perioperative nursing diagnoses flow sheet used at DePaul Health Center, St Louis, has room for additional nursing documentation and signatures.
MARCH 1995, VOL 6 1, NO 3 Null
Hii
Irtri - A h
Koiw
PILOT PROGRAM
IMPLEMENTATION
After the NDTF members worked on the flow sheet development project for one year, they initiated a pilot program. They chose neurosurgical patients for the pilot program because these patients were a small percentage of total health center surgical volume, exposed to all phases of perioperative care, and a mix of inpatient and outpatient populations. One NDTF member and staff nurses from each phase of perioperative care participated in the pilot program. The staff nurses who participated in the pilot program attended a two-hour education session, reviewed the flow sheet objectives and instructions, and practiced with the flow sheet using different patient scenarios. The NDTF maintained control of patient selection for the pilot program by following this process. The PAT coordinator identified patients scheduled for neurosurgery procedures. The PAT coordinator provided the outpatient nurse manager with a list of patients. The outpatient nurse manager assigned a pilot program staff nurse to care for the patient in the pretesting, preoperative, and PACU I1 phases of care. The neurosurgical OR team members reviewed the surgery schedule daily and prepared for participating clients. An NDTF member from PACU I reviewed the daily surgery schedule and notified the PACU manager of any pilot patients who would be in the PACU. The PACU manager made staffing assignments accordingly. This system was successful in capturing the majority of patients who were eligible for the pilot program. The perioperative nursing diagnoses flow sheets being pilot tested were not placed in the patients’ charts on a permanent basis because the flow sheets had not received final approval by the medical records department. The pilot project group and NDTF members met to review the completed flow sheets after the one-month pilot program period. The NDTF spent an additional two months making suggested content and format changes to improve and condense the flow sheet material. The NDTF submitted the final perioperative nursing diagnoses flow sheet for approval by the nursing practice council in accordance with nursing departmental policy. The perioperative nursing diagnoses flow sheet then went to the medical records form committee for final approval, which was received in January 1993.
After the pilot program and multiple revisions were completed and approvals received, the NDTF was ready to use the flow sheet throughout the perioperative area. The next challenge was to educate more than 50 RNs about the flow sheet process and meet the anticipated resistance to change. Each staff nurse on the NDTF was responsible for educating his or her own department. Each nurse used the same teaching method but was able to satisfy the specific needs and requirements of his or her department. The task force members’ goal was to educate all staff nurses in one month. Each educator limited the inservice sessions to one and one-half hours in length with three to six staff nurses in attendance per session. To maintain consistency, the nurse educator used an overhead projection of each nursing diagnosis to demonstrate flow sheet documentation. Step one of the education process included a general overview of the perioperative nursing diagnoses flow sheet with its philosophy, goals, and objectives. Next, each nursing diagnosis was addressed with a scenario depicting primary examples relevant to a typical patient i n the specific department. This approach created an atmosphere in which additional department-specific questions could be raised and addressed. The NDTF believed that a small number of employees in each group would promote a stronger understanding of the flow sheet and allow the educator to give staff nurses individualized attention. Each education session was productive because the educator held expertise in both the flow sheet development and in the nursing care provided by the specific department. The initial education process was completed one and one-half weeks before the preestablished one-month goal. The education sessions quickly resolved staff members’ initial fears regarding the flow sheet. The NDTF wasted no time implementing the flow sheet as a pennanent part of patients’ charts. The learning process continued through the first few weeks of implementation. Staff nurses in the PACU provided important input in the continued learning process because they were able to review flow sheets with three phases of care already completed. When questionable or incorrect documentation occurred, the PACU nurses alerted their task force member. With this timely information, the primary NDTF members could address questions and errors within their own departments. 554
AORN JOURNAL
MARCH 1995, VOL 61, NO 3 - N u / / Richter-Aht Kovac
CONCLUSION
The NDTF created and implemented a documentation tool that combines nursing diagnoses and includes all phases of perioperative nursing care. The perioperative nursing diagnoses flow sheet is easy to complete and uses documentation time more efficiently. Also, the flow sheet meets the JCAHO nursing standards that relate to nursing diagnosis documentation. Constructing and implementing the perioperative nursing diagnoses flow sheet was time-consuming and required each department to review and change records that the flow sheet might duplicate. As with any change, there remains some resistance to the use of the flow sheet; however, most perioperative staff members have learned to use the flow sheet and integrate it into their practices with little NOTES 1. Joint Commission on Accreditation of Healthcare Organizations, “Nursing Care,” in 1993Joint Com-
difficulty. The perioperative nursing diagnoses flow sheet, as with all perioperative documentation tools, will be periodically reviewed and revised. A Sandra Null, RN, is coordinator of preadmission testing and surgery at DePaul Health Center, St Louis. Diane Richter-Abt, RN, BS, is a postanesthia care unit stajjf nurse at DePaul Health Center, St Louis. Jane Kovac, RN, is employment supeivisorlnurse recruiter at DePaul Health Center, St Louis. The authors would like to thank the other nursing diagnosis task force members, Sue Denningman, RN, and Linda Franklyn, RN,for their efforts and support.
mission Accreditation Munual for Hospitals (Oakbrook Terrace, 111: Joint Commission on Accreditation of Healthcare Organizations, 1992) 79-80.
2. L J Carpenito,Nursing D i q nosis Application to Clinical Practice, fourth ed (Philadelphia:J B Lippincott Co, 1992) 7-9.
Lacing Shoes Properly Can Prevent Foot Problems Women are discovering that the way they lace their shoes can make shoes fit better and also can prevent foot problems later in life. Because most women’s athletic shoes are scaled-down versions of men’s shoes, they do not fit women’s feet appropriately. Learning certain lacing techniques can improve the fit of many of these shoes, according to an Oct 1 1, 1994, press release from the American Academy of Orthopaedic Surgeons. Shoes with a large number of eyelets offer the most lacing options and allow the best custom fit, the release states. Women with narrow feet should use the eyelets farthest from the tongue of the shoe. This technique brings the sides of the shoe up higher and helps them fit tightly across the top of the foot. Women with wide feet should use only the eyelets closest to the tongue to allow the most space within the shoe-like letting out a corset, according to the article. Women often have problems finding athletic shoes that fit their heels properly because many shoes have heels that are too big for women’s feet. To prevent heel pain and blisters, the release states, every eyelet on the shoe should be used. At the next
to last eyelet on each side, the lace should be threaded through the top eyelet rather than crossing over to the eyelet on the opposite side. This forms a small loop, through which the opposite lace should be threaded before tying the laces. The area closest to the heel (ie, the top of the shoe) should be tied the tightest; less tension should be used toward the toes, the release states. Women who choose smaller shoes to ensure a proper fit in the heel often have foot deformity and pain as a result of shoes that are too tight in the forefoot area. The release states that 73% of women chose shoes for the heel fit and experienced foot pain as a result. In addition to learning lacing techniques, women also should try shoes on at the end of the day when their feet are the largest and make sure the forefoot is not crowded in the shoe (ie, make sure that toes can extend). According to the release, the shoe should be 1/2 inch longer than the longest toe. Lacing Techniques Make Women’s Shoes Fit Better (news release, Rosemonf, 111: American Academy of Otfhapaedic Surgeons, Oct 1 1, 1994).
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