Integration of Problem Identification
with Assessment - FAQ’s
Question
1. What is the definition of
“WNL”?
2. If the category does not apply
to their patient , does it need
to be documented against?
3. What Problem should be used
to describe generalized
weakness (such as that
experienced by Hem Onc.
Patients receiving chemo)?
Answer
1. 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.
2. 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.
3. Generalized weakness checkbox was under the
muscle strength section. Use FATIGUE in the Activity
drop –down box which is in ACTIVITY/MUSCULOSKEL
category.
4. What if a patient has more
than one Problems in a
category (eg. GI: both
diarrhea & n/v)?
4. Select all that apply (the drop down list is multiselect). 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)
5. Should all co-morbidities
automatically trigger selection
of a Problem?
5. 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.)
6. 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.
6. What Problem should be used
if a patient has sickle cell
disease?
Integration of Problem Identification
with Assessment - FAQ’s
Question
Answer
7.
My patient has issues with
performing several ADLs. Do
I need to select all
applicable Problems in Self
Care section?
7.
8.
Many of my patients have
multiple Problems. Do I
have to start a Priority
Problem for all of them?
8.
9.
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)?
10.
9.
10.
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.
Integration of Problem
Identification with Assessment FAQ’s
Question
Answer
11.
Where should cellulitis be
charted?
11.
12.
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?)
12.
13.
For an autistic child – how
should this be documented?
13.
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.