Question

• Reflect on the concepts of informatics and knowledge work as presented in the Resources.
• Consider a hypothetical scenario based on your own healthcare practice or organization that would require or benefit from the access/collection and application of data. Your scenario may involve a patient, staff, or management problem or gap.

Answer 1

Greetings of the day!

Answer:

A simple, electronic workflow helps standardize and improve communication of direct care in keeping with the ANA documentation standards (2010), as in the following focused-care example.

• Assessment: Data provide information for nurses to arrive at specific clinical judgments (diagnoses/problems).
• Diagnoses/Problems/Clinical Judgments: Appropriate outcome identification, planning, and implementation of interventions are not random actions, but are actions that are assessment-and-diagnostic-specific.
• Outcome Identification and Planning: In these two standards, nurses specify the intervention(s) to be used to achieve the desired outcomes, both process outcomes and clinical outcomes.
• Implementation: Engage the individual/family/community/population in care planning and on the implementation of interventions. Conduct on-going vigilance and act to prevent or to reverse movement toward outcomes that are undesired. Initiate rescue, as needed.
• Evaluation: Document patient outcomes and make summative statement/analysis, e.g., condition stabilizing/worsening. Continue to modify plan to achieve desired process and clinical outcomes

Patient scenario: 68 year old female admitted to nursing unit with diagnosis of pneumonia and history of heart disease. Temperature at 101° F; blood pressure 148/92; heart rate 96/min (regular rate and rhythm); respiratory rate 28/min; and pulse oximetry 93%. Patient denies pain but complains of increasing fatigue, cough and shortness of breath. The admitting RN documents the initiation of intake and output; daily weights; and vital signs; including pulse oximetry, four times daily.
Standard 1. Assessment	Documentation
RN collects comprehensive data pertinent to the healthcare consumer’s health or the situation.	Over the course of the next few days, the RN staff collects pertinent data. Intake and output records reveal an alarming fluid volume overload. Vital signs reveal a decrease in fever but a steady increase in systolic and diastolic pressures, increasing heart rate, and slowly declining oxygen saturation.
Standard 2. Diagnosis	Documentation
RN analyzes the assessment data to determine the diagnoses or issues.	There is apparently no attempt to analyze the data or report it to the attending physician. Fluid volume overload is not mentioned in the patient record, although the patient’s fall risk and skin integrity are noted.
Standard 3. Outcome Identification	Documentation
RN identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.	No expected outcomes are identified. There is also no mention of the increasing risk of pulmonary edema/congestive heart failure due to increasing fluid volume overload. On the fourth day, the patient develops acute pulmonary edema and is transferred to Intensive Care Unit (ICU).
Standard 4. Planning	Documentation
RN develops a plan of care that prescribes strategies and interventions to attain expected outcomes.	While the prior plan of care included appropriate surveillance activities (e.g. intake and output, daily weights, pulse oximetry and appropriate vital sign monitoring), nothing was done to conduct surveillance at regular intervals or to adapt the plan of care appropriately – i.e., report and control fluid volume overload and report signs of impending heart failure to the physician. In other words, electronic nursing documentation of surveillance activity was haphazard and findings did not lead to appropriate implementation.
Standard 5. Implementation	Documentation
RN implements interventions identified in plan.	This case scenario begins and ends with the collection of data. There was no documented professional analysis of the data or diagnosis, nor was a plan of care appropriate to the patient’s needs documented.
Standard 5A. Coordination of Care	There was no documented coordination of patient care.
Standard 5B. Health Teaching and Health Promotion	There was no documented health teaching or health promotion.
Standard 5C. Consultation (Graduate Prepared Specialty or APRN)	Not applicable
Standard 5D. Prescriptive Authority and Treatment (APRN)	Not applicable
Standard 6. Evaluation.
RN evaluates progress toward attainment of outcomes.	Patient outcomes (pulmonary edema) could have been prevented had assessment data been correctly analyzed and the diagnosis of fluid volume overload recognized. As it was, the patient was admitted to ICU, appropriate treatment was initiated, and patient was discharged home, but length of hospital stay had been extended and the patient now has a history of congestive heart failure, recent onset.