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Healthcare Informatics Resources. (2013, April 29). Nursing Informatics and health Assessment [Blog post]. Retrieved from https://healthcare-informatics-resources.com/2013/04/29/human-computer-interaction-hci/
I completely agree with this post about nurses needing to learn and get trained in using the computer programs at work. When I was taught through my job, I was taught by someone who had only one day of training. I had to base my knowledge off of what she remembered. I also had to trust that she was doing it right and that she was showing me a good way to learn and remember. If I would have had a day or more of training then I would have been ok with making mistakes and doing things wrong. But when you are just thrown into something and then do it wrong it could jeopardize your job, especially when it has to do with patient information.
The concept of nursing informatics is challenging to many nurses. Nurses may be extremely competent in their fields however, a lot of them do not feel as competent when it comes to using technology to access patients information, search for information and resources or document in an electronic medical record. Hospitals and other clinical settings should provide adequate training programs for nurses as well as have a way to assess competency in nursing informatics. With appropriate training, nurses performing a health assessment would be able to access relevant patient information such medical history and results of diagnostic studies. Many health care settings also offer access to online patient education materials. Nurses should know how to access resources for patient teaching and also how to test the reliability of the sources. For instance, reliable sources should come from well-known journals or have traditional history of print. Knowledge of nursing informatics is a valuable tool for nurses performing a health assessment.
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I used to work for Children’s Hospital in the IMU unit. Many times, we as nurses would encounter many genetic disorders that were foreign to us or we just did not know enough about the disorder to help educate their parents. Since I also took classes in genetics, I found myself digging further into a particular website OMIM. This website was extremely useful in providing information on genetic diseases and compiled all the information and studies on each genetic problem. This was useful because if children were not reaching their physical or emotional development, many times this was addressed within the study and what was “normal” for that disease process. Many families were at a loss and just did not understand the disease process. The Internet was extremely useful in educating parents and myself regarding the physical and emotional assessment of their child. Also we could print out valuable information and documentation to explain to parents with diagrams and help teach parents about the disorder and what they could expect in the future. I found the Internet to be extremely helpful in ways that books could not.
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I have two children who suffer from seasonal allergies. Their symptoms are similar, usually characterized by rhinitis and frequent sinus infections. These recurrent problems often lead to frequent trips to the doctor’s office. In the past, I’ve been asked by the doctor to keep a hand written account of their symptoms to take back to the office. I believe that if the information could be sent to the doctor electronically, it would be more convenient for the pt, and the doctor could share the information with other clinicians. The data could also be organized to look for any patterns between patients.
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Completing a thorough head to toe assessment is a skill that takes practice and a broad knowledge base. No body system stands alone. Completing a quality assessment of one system may lead to clues about issues or problems in another system. Although head to toe exam is recommended, it is important for clinicians to develop methods that work for them. Patients may present with acute symptoms or complaints that do not allow time for a comprehensive exam. It is vital for the nurse to be able to discern what level of assessment is required for each individual. A patient who is in obvious distress will require a much focused assessment and relatively quick intervention. The type of assessment can also be affected by the health care setting. Nurses working in an outpatient setting may have more time to complete a comprehensive exam and history. Nurses working in hospitals may have multiple patients with various problems that require focused assessments for the sake of efficiency. Some may have a modified head to toe examination technique. Documenting assessment findings have been greatly facilitated in the facility for which I am employed. Each patient room is equipped with a computer to allow for immediate entry of assessment findings. All units have at least five to six, computers- on-wheels (COW) that can be taken from patient to patient if needed. It is interesting to observe the level of competence exhibited by nurses. Novice nurses tend to take copious notes on each system while more experience nurses can gather much information about his or her patients during the general survey. As assessment skills develop, nurses can gather information with minimal effort.
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The quantity and quality of nursing charting can be improved by using Computer On Wheels, or an electronic hand-held or similar device. Your health assessment skills will definitely take a turn for the better.
Original Post
March 3, 2011
The Importance of Health Assessment
As a seasoned nurse I think I perform a pretty good assessment. However, reading the first four chapters of our textbook and doing the first lab exercise has reminded me about a basic concept that in our fast pace world we tend to loose sight of. That is the concept asking open ended and non-judgmental questions and then listening to the answers and asking follow up questions. Today’s healthcare environment doesn’t allow for much time but I realize I can better utilize the time I have by improving my assessment skills of asking questions and listening more to the answers I receive.
In an age of electronic records and an economic recession, the nurse must be diligent about thoroughly assessing the client using a head-to-toe format and charting all findings in detail. Medicaid/Medicare has really tightened their laws on what they will and will not reimburse. For example, if a patient is admitted to the hospital and the nurse fails to chart that the client had an already present pressure ulcer, Medicare will refuse to reimburse the hospital for fees, supplies, and procedures related to the treatment of that wound. However, if the pressure ulcer is charted as being present upon arrival, the hospital is not at fault and will be reimbursed fully. Another example, separate from charting, is when a patient is discharged from the hospital following a heart failure “tune-up” and is readmitted within 30 days. The hospital in penalized for the re-admission. The problem is that there are other factors that could cause the re-admission that is not the fault of the hospital or physicians. What if the patient is non-compliant with the prescribed medication regiment? Should the hospital be a fault? Also, we care for a high risk, end stage heart failure population, so is it fair that our stats must match up to a rural hospital that only cares for mild cases of heart failure and does not perform transplants?
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With the assessment of the pregnant client, healthcare informatics comes quickly to mind. The use of healthcare informatics is beneficial and necessary with the pregnant client. The benefits of using an electronic medical record (EMR) with the pregnant client is important and necessary. The benefits of having this record readily available and up-to-date ensures appropriate and timely health care of this client especially in an emergency or high risk situation. This also ensures appropriate and timely health care for the fetus to also assist in producing positive health care outcomes.
With healthcare informatics and the diagnostic testing that is available to the pregnant client and fetus are concise and thorough. Diagnostic evaluation and intervention also allows timely and accurate care of the pregnant client. With any assessment, the pregnant client needs a complete evaluation with analysis of the fetus. This assessment needs to be detailed with follow-up on any issues if they should arise. With any issues, the follow-up should be quick to ensure the safety of both client and fetus. Seek resources if needed for clinical issues with this client. This assessment ensures safety but also positive clinical outcomes.
ICU nursing frequently involves caring for the patient who is artificially ventilated. This could be for numerous reasons: i.e. failure to wear off ventilator following surgery, respiratory failure, PE, pneumonia, etc. Without advances in informatics, care of this difficult patient would be made even more difficult. Assist controlled ventilation is the most often used. In this mode, tidal volume and rate are pre-set. In other words the ventilator is taking over the work of breathing, filling the lungs with air and enabling gas exchange to occur so the patient remains well-oxygenated. If the patient does indicate respiratory effort, the ventilator is programmed to respond though it still delivers the preset tidal volume. Nurses must be attentive to the patient’s respiratory rate and the ventilator’s assistance in order to avoid hyperventilation and subsequent respiratory alkalosis. Generally, the nurse checks and records ventilator settings and respiratory effort frequently throughout the shift. The patient will be monitored with vital signs, cardiac rate and rhythm, respiratory rate and pulse oximetry, via electronic monitors which transmit information directly to nurses in preset intervals (often as frequently as 2-5 minutes) and alarm when abnormals occur. Without this form of monitoring, care of this patient would be much more difficult. If the ventilator is alarming, the nurse attends to the patient first, then, if all is well, attends to the alarms which may indicate water in the tubing or a loose connection. The patient should be assessed for skin color (nail beds and lips particularly), lung sounds, bilateral chest expansion, need for suctioning and respiratory effort. The physician may order labs, arterial blood gases, chest x-ray or alteration of settings. Again, thanks to computerized information retrieval continuity of care on a multi-disciplinary level is more accessible than in the past. In most ICUs, physicians, nurses and respiratory therapists have access to electronic bedside charting to allow for continuous monitoring. This form of charting makes the work of documentation and information retrieval safer for the patient. Simply put, breathing supplies the human anatomy with life-giving oxygen a necessity for every cell in the human body; thus the “A” in ABCs. Nurses always must attend to airway first, for without a patent airway, no other intervention could help the patient achieve homeostasis.
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