Integration of Problem Identification with Assessment - FAQ’s

1. Integration of Problem Identification with Assessment - FAQ’s • Within normal limits (WNL) indicates absence of significant problems in the Care Category drop-down list.  Problems are significant when they may affect the nursing plan for care or should be communicated to the next caregiver. • On admission, all Care Categories assessed for Problems. Thereafter, Only the CAPITALIZED Categories must be assessed every shift. Other categories are assessed as appropriate for patient/family situation. • Generalized weakness checkbox was under the muscle strength section.   Use FATIGUE in the Activity drop –down box which is in ACTIVITY/MUSCULOSKEL category. • Select all that apply (the drop down list is multi-select). It is possible to have a baseline issue and a problem within the same Care Category (eg. Pt. with long history dementia admitted for hip fx. With knowledge deficit – would have Neuro/Cognitive baseline and problem) • No, if they are not the reason for admission, are under control, and/or do not result in special (not standard) nursing care. (See question 9 about “Baseline” definition for more details.) • Focus on Problems rather than medical diagnoses causing the problems. For Sickle Cell, you might expect to see Pain, Tissue Perfusion, Nutrition, Infection Risk(Physical Regulation), Activity Intolerance or Fatigue, and Coping issues so would focus on problems patient is experiencing because of the underlying disease process. No two pts. will have exact same responses. Question Answer What is the definition of “WNL”? If the category does not apply to their patient , does it need to be documented against? What Problem should be used to describe generalized weakness (such as that experienced by Hem Onc. Patients receiving chemo)? What if a patient has more than one Problems in a category (eg. GI: both diarrhea & n/v)? Should all co-morbidities automatically trigger selection of a Problem? What Problem should be used if a patient has sickle cell disease?

2. Integration of Problem Identification with Assessment - FAQ’s Question Answer In general, when there is data to support, it’s better to identify the most specific Problems when doing the Problem Assessment. However, for patients with multiple ADLE issues, “ADL – Basic” is a more generic, umbrella term that includes the sub categories – bathing, dressing/grooming, toileting, etc. Unless one specific ADL issue is the overwhelming challenge for this patient, it might be more manageable to select the more generic “ADL-Basic” as a Priority Problem ( assuming this is a priority for your shift). NO! We still want to focus on the top 2-4 Problems you can address on your shift. (considering patient/family goals, issues that nursing has most potential to impact, issues that are preventing progression toward discharge). See the new option (available on or before Aug. 6) “Baseline (annotate)”. Baseline = Patient has chronic deviation from normal that will not impact plan for this episode of care. YES! A full pain assessment (resulting in a pain score if possible) is done using the age/situation-appropriate scale at the beginning of each shift and per Pain policy. • My patient has issues with performing several ADLs. Do I need to select all applicable Problems in Self Care section? • Many of my patients have multiple Problems. Do I have to start a Priority Problem for all of them? • Many of our patients have chronic Problems that are well controlled or for which they employee effective accommodation (eg. Hypertension well controlled with medication). Do I document WNL or select a Problem when doing my initial assessment on admission? • If I document under Pain Problem Assessment “WNL” do I still have to do a Pain Assessment (using FLACC or other Pain scale)?

3. Integration of Problem Identification with Assessment - FAQ’s Question Answer The Problem might vary from one patient to the next since cellulitis manifests in varying ways. Consider Impaired Skin Integrity ,Skin Integrity Risk, or Infection based on extent to which Skin Breakdown already exists or seems likely. We will be expanding on changes made to introduce Problem identification in the coming months. Initially, you will see fully fleshed out capability to document interventions (including assessments, care, teaching, and notification) for the 5 remaining Functional Care Categories (Fluid, Nutrition, Activity, Self Care, Sensory) . Once those are complete, the other Physiologic and Psych/Behavioral Categories will be added. Until then, see the places to document about Edema that already exist in the Cardiac Care Category. These will likely be shifted to Tissue Perfusion category soon. Given the wide range of autism spectrum disorders, focus on the Problems the child manifests. Thought Process Disorder, Growth and Development Risk, Socialization Alt., Communication Impairment, and Anxiety are Problems you may see with patients who are autistic. • Where should cellulitis be charted?  • Under fluid for Fluid Excess – under the “problem list” could there be a section to chart “edema” with a drop down for Location and scale (identical to the “edema” section currently under cardiac?) • For an autistic child – how should this be documented?