Current through Register Vol. 24, December 22, 2023
(1) The registered
nurse shall conduct and document nursing assessments of the health status of
individuals and groups by:
(a) collecting
objective and subjective data from observations, examinations, interviews, and
written records in an accurate and timely manner. The data includes, but is not
limited to:
(i) biophysical, emotional, and
mental status;
(ii) growth and
development;
(iii) cultural,
spiritual, and socio-economic background;
(iv) family health history;
(v) information collected by other health
team members;
(vi) client knowledge
and perception about health status and potential, or maintaining health
status;
(vii) ability to perform
activities of daily living;
(viii)
patterns of coping and interacting;
(ix) consideration of client's health
goals;
(x) environmental factors
(e.g., physical, social, emotional, and ecological) ; and
(xi) available and accessible human and
material resources;
(b)
sorting, selecting, reporting, and recording the data;
(c) validating, refining, and modifying the
data by utilizing available resources, including interactions with the client,
family, significant others, and health team members.
(2) The registered nurse shall establish and
document nursing analysis which serves as the basis for the strategy of
care.
(3) The registered nurse
shall develop the strategy of care based upon data gathered in the assessment
and conclusions drawn in the nursing analysis. This includes:
(a) identifying priorities in the strategy of
care;
(b) collaboration with the
client to set realistic and measurable goals to implement the strategy of
care;
(c) prescribing nursing
intervention(s) based on the nursing analysis; and
(d) identifying measures to maintain comfort,
to support human functions and positive responses, and to maintain an
environment conducive to teaching to include appropriate usage of health care
facilities.
(4) The
registered nurse shall implement the strategy of care by:
(a) initiating nursing interventions through:
(i) giving direct care;
(ii) assisting with care;
(iii) assigning and delegating care;
and
(iv) collaborating and/or
referring when appropriate;
(b) providing an environment conducive to
safety and health;
(c) documenting
nursing interventions and responses to care to other members of the health
team; and
(d) communicating nursing
interventions and responses to care to other members of the health
team.
(5) The registered
nurse shall evaluate the responses of individuals or groups to nursing
interventions. Evaluation shall involve the client, family, significant others,
and health team members.
(a) Evaluation data
shall be documented and communicated to appropriate members of the health
team.
(b) Evaluation data shall be
used as a basis for reassessing client health status, modifying nursing
analysis, revising strategies of care, and prescribing changes in nursing
interventions.
(c) Research data
shall be utilized in nursing practice.
NEW, 1985 MAR p. 1556,
Eff. 10/18/85; AMD, 1997 MAR p. 626, Eff. 4/8/97; TRANS, from Commerce, &
AMD, 2006 MAR p. 2035, Eff. 8/25/06.
37-1-131,
37-8-202,
MCA; IMP,
37-1-131,
37-8-202,
MCA;