Using an A+D = A Approach to Nursing Assessment & Performance

By Ava Sammarco

A (Assessment) + D (Documentation) = Action 

Assessment

The basis of nursing care rests on the ability of the nurse to utilize assessment of the patient as the first step of the nursing process (Toney-Butler & Thayer, 2020). The power behind the assessment serves as the foundation for the basis and delivery of care and as such it is important that nurses sharpen and hone their assessment skills daily. We have all been impacted by the current health pandemic and yet, it has never been more important to refocus and dedicate our efforts to this crucial step of the nursing process. 

Assessment data (subjective and objective) is collected and reviewed and within this first step of the nursing process, establishes the framework for delivery of care. Without a proper assessment done in a timely manner, patient care outcomes can be severely affected. Thus, assessment remains the critical foundation of nursing care. 

Documentation

With the completion of assessment, the nurse must use documentation to note findings and convey information leading to a plan of action. The old adage, “if it is not documented, then it is not done”, remains as the cornerstone of ethical/legal principles and nurses should be empowered by their sense of duty, responsibility, and accountability to make sure that their documentation is accurate and within the defined parameters of timeliness (McBride et. al., 2018). Electronic health records (EHRs) have led to the creation of a checklist/templated framework that contains both advantages and disadvantages. 

Advantages relate to the consistency and format of the note whereas the disadvantages relate to the concept that if there isn’t a box or checklist component, nurses may have little experience and/or impetus to create a narrative note. Too often in this electronic age, where technology has taken over the documentation of healthcare practice, the narrative note has gone by the wayside. Nurses should utilize documentation effectively, accurately, and most of all, comprehensively to ensure that nothing is missed on the patients’ health record. 

Action 

Implied in the action statement is the nurses’ inherent duty to function as an advocate for his/her patients who are sick and under their care. Nurses are not merely performers of health-related tasks but rather have demonstrated themselves as part of the frontline heroes of the healthcare profession. Dimino et.al. (2020) suggests that nurses should focus on their ability to utilize their psychological capital (PsyCap) which manifests as HERO levels (hope, efficacy, resilience, and optimism) to be better prepared to face the health pandemic challenges. 

Nursing care is comprehensive containing both qualitative and quantitative measurements and literally, the nurse (at the bedside or functioning at the clinic or in the community) serves as the intermediary for the patient as it relates to healthcare delivery.  Following through on assessments and documentation, the nurse plays a critical role in the planning, implementation, and evaluation of care. The coordinated action of the nurse to function as a member of the interdisciplinary care team is fundamental to improving better health outcomes for patients. 

Let’s do the Math – A + D = A Which Leads to Better Health Outcomes 

So, let’s do the math, so to speak, and make sure that nurses perform their due diligence, by starting out with assessment, followed by documentation, and leading to action. Each step of the process can become somewhat cyclical in nature. Healthcare is not a static interface but rather nurses and all healthcare providers must continuously assess, document, and act and repeat the process until the healthcare issue is resolved and/or healthcare outcome is improved. No longer does the healthcare of the patient exist in isolation and all members of the healthcare interdisciplinary team must be part of the process.  

References:

Dimino, K., Horan, K. M., & Stephenson, C. (2020). Leading our frontline HEROES through times of crisis with a sense of hope, efficacy, resilience, and optimism. Nurse Leader, 18(6), 592–596. https://doi.org/10.1016/j.mnl.2020.05.011

McBride, S., Tietze, M., Robichaux, C., Stokes, L., & Weber, E. (2018). Identifying and addressing ethical issue with use of electronic health records. OJIN, 23(1). https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-23-2018/No1-Jan-2018/Identifying-and-Addressing-Ethical-Issues-EHR.html

Toney-Butler, T.J. & Thayer, J.M.  [Updated 2020 Jul 10]. Nursing process.  In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499937/


Bio‐ Daryle Wane, Ph.D., APRN, FNP-BC

Daryle Wane, PhD, APRN, FNP-BC has 41 years’ experience in the professional discipline of nursing and 29 years’ experience in higher education and is currently the BSN Program Director of the Bachelor of Science in Nursing Program at Pasco-Hernando State College in New Port Richey, Florida. Dr. Wane has taught nursing classes across the curriculum and designed nursing programs functioning as a subject matter expert and participant member of the Instructional Technology Design team.  

Dr. Wane has also authored several publications in nursing and nutrition and serves as a Peer Reviewer for several journals/organizations as well as being an Academic Editor/Editorial Review Board Member for several medical and nursing journals. Dr. Wane has given several keynote addresses at state, national, and international levels and served as an organizing committee member (2nd Florida Nursing Association (FNA) Nursing Research & Evidenced-Based Practice Nursing Conference in 2016, 2nd National Nursing World (NCW) Conference in Las Vegas in 2017, and the 2nd Global Conference on Nursing & Healthcare in London in 2018.

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  33. Alice Perkins says:

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  34. Jessica Amber says:

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  35. A good day out there! I am Catherine, and I live in NY. I am particularly very grateful to Daniel Meuli Recovery for their timely and reliable services in helping me recover the $62,500 worth of BTC I had lost; thereby saving my business!… I want to use this opportunity to say a big thanks to them again and also let everyone out there who is facing similar or related issues hurriedly reach out to them. Listed below is the medium to contact Daniel Meuli Recovery directly: Danielmeuliweberecovery @ email. com or WhatsApp +39351201352

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  37. Neels Ainar says:

    HOW DID I GET ACCESS TO MY CRYPTOCURRENCY WHEN THE TRADING PLATFORM DID NOT ALLOW ME TO WITHDRAW MY FUNDS I was introduced to a cryptocurrency trading platform smatdec. me. where I invested my entire savings, they didn’t allow me to withdraw my profits or my investment funds even after paying all sorts of ridiculous fees. I’m a disabled veteran and losing my funds to these platforms has caused me all forms of financial distress and depression. I was very lucky to have come across Spyweb Cyber Security Service, which was able to help me recover my crypto after their investigation, they found out the platform was a scam site and was only after my investment funds. Spyweb Cyber Security Service was able to recover all my funds. I’m truly grateful and I highly recommend their services to everyone affected by this scam.
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  38. Ben Pesci says:

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  40. Recovery Intel says:

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  41. Claire says:

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  42. Mr john says:

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  43. Martin Aidan says:

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  44. Sophia Richardson says:

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  45. Harry Garnet says:

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  46. Stormi Kim says:

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  47. Nick Mike says:

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  48. Adam Green says:

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  49. Recovery Intel says:

    ARE YOU A VICTIM OF INVESTMENT OR NFT SCAM? DO YOU WANT TO INVESTIGATE A CHEATING SPOUSE? DO YOU DESIRE CREDIT REPAIR (ALL BUREAUS)? SCHEDULE A MEETING WITH AN ETHICAL HACKER ASAP TO GET STARTED.

    ASOREHACKCORP is a financial regulator, private investigation and funds recovery body. We specialize in cases as regards ETHICAL HACKING, CRYPTOCURRENCY, FAKE INVESTMENT SCHEMES and RECOVERY SCAM. We are also experts in CREDIT REPAIR, we analyze what’s impacting your score.
    All software tools needed to execute RECOVERIES from start to finish are available in stock.
    Kindly NOTE that the available tools does NOT apply to CREDIT FIX.

    Be ALERT to FALSE reviews and testimonies on the internet, the authors and perpetrators unite to form a syndicate.

    Contact our team as soon as you can via the email address below to book a mail meeting with an ethical hacker.
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    Stay Safe out there !

  50. Leilah Abdullahi says:

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  51. linda says:

    linda
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  52. Can scammed money be recovered? Yes through Captain WebGenesis.

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  53. As a victim, I was ripped off when I invested in cryptocurrencies because I got into the wrong hands and had $845,000 in BTC stolen from me. I was about to lose up after hearing that it couldn’t be found or recovered, but fortunately I came across an online post about a recovery specialist named Jeanson James Ancheta wizard. I contacted him and did some work with them just to give it a try. I never thought it would be feasible, but to my greatest amazement, they were able to recover $545,860 of the money that was taken from me. I’ve decided to share this with anyone who might require such a service. Regarding BTC recovery, Jeanson James Ancheta wizard provides an incredible service. Contact him on email:(jeansonjamesanchetawizard62@gmail.com) or WhatsApp number: +447529524472.

  54. The decentralized digital money known as Bitcoin has become very popular in the last few years. However, as cryptocurrencies become more widely used, there is a chance that users will lose access to their money because of device malfunctions, lost passwords, or other unanticipated events. In the realm of Bitcoin recovery, this is where Fayed Hacker Recovery shines as a revolutionary solution. Ah, Bitcoin – the digital gold that everyone’s talking about. It’s no secret that Bitcoin has taken the world by storm, and with its growing popularity comes an increased risk of losing access to your precious funds. But fear not, my friends, for I bring you exciting news. Introducing  Fayed Hacker Recovery , the ultimate game changer when it comes to Bitcoin recovery. The bright lights of the Bitcoin world are  Fayed Hacker Recovery. What distinguishes them from the others? Well, this is where things get exciting, so hold onto your broomsticks.  Fayed Hacker Recovery uses an innovative approach to assist you in getting your lost money back. Having the ability to make your Bitcoins reappear in your digital wallet is like having a magic wand. Quite remarkable, isn’t that right? They don’t possess a crystal ball, but they can follow transactions, analyze blockchain data, and locate your misplaced cash thanks to their state-of-the-art technology. With their track record of successfully recovering lost Bitcoin and their commitment to security and customer satisfaction,  Fayed Hacker Recovery is poised to play a significant role in the future of Bitcoin recovery. They are at the forefront of innovation and are constantly exploring new ways to enhance their services. For your problems with digital currency, it’s like employing Sherlock Holmes. Call Fayed Hacker Recovery via :   (writeus AT fayedhacker DOT tech)    WhatsApp : (+44 7462 203648)   Signal : +1 313_264_2635   Website : http://fayedhacker.tech

  55. HOW TO FIND LOST BITCOIN // CONSULT CAPTAIN WEBGENESIS.

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  57. Stefan Ward says:

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  58. Werner Ehrhardt says:

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  59. Okoh Patience says:

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  60. Isabelle says:

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  62. Mavis Wanczyk says:

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  63. Diego Carreon says:

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  64. mary christina says:

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  65. adalynn nora says:

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  66. Bailey Duarte says:

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  68. Bren says:

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  69. Paul Gilles says:

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  71. Stacy K Davis says:

    RECOVERY EXPERIENCE WITH THE EXNER HACKER
    On a Facebook investment page, I got interested in Ethereum cryptocurrency mining and I was sent a link for a company with which I could invest, fun-eth.com. I opened a Coinbase wallet and transferred money to fun-eth.com with Anthony Wilson’s encouragement. Promising that if I invested $600,000 and the company reached the investment goal, I would qualify for the premium big fish seven Ethereum welcome token. Not only did I lose the $600,000, but the scammers were able to steal another $98,000 from the wallet I gave to them. They then told me that I needed to invest another $300,000 by a given date to get access to withdrawals on my account. I contacted a Friend in New Jersey who has been making his way on BTC, he advised me not to make any more payments but instead seek help to recover the earlier investment. He recommended The Exner Hacker, who had helped him on earlier Bitcoin recovery. I mailed them via Theexnerhacker@protonmail.com. It has been over two months since I got my dollars back. Thank you sir and your team for the work well done.

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