Documentation/Growth/Development/Nutrition/Sleep Flashcards
Learn about nursing documentation by exploring the CNO Practice Standard Review the nursing process and apply these principles to developing pediatric nursing care plans Discuss the application of growth and development to pediatric nursing practice Consider relevant nutrition, sleep and safety concerns for infants and children
What are some of the main reasons for documentation?
- Reflects the client’s perspective
- Communicates to all health care providers
- Demonstrates safe, effective and ethical care
- Demonstrates application of knowledge, skill and judgment
- Meet legislative requirements
- Data from documentation has many purposes
What are the principles of documentation according to CNO?
1) Communication
2) Accountability
3) Security
What is the different type of documentation?
- Paper
- Electronic
- Audio / Visual – state it and dictates into paper, CT, urine sample, blood work
Explain the principle of communication in documentation
“Nurses ensure that documentation presents an accurate, clear and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes”
- Documents a complete record of nursing care provided and reflects all aspects of the nursing process
- Uses appropriate signature and designation
- Uses abbreviations and symbols appropriately
Explain the principle of accountability in documentation
“Nurses are accountable for ensuring their documentation of client care is accurate, timely and complete”
- Documents during or as soon as possible after the care – can’t possibly remember everything – pt can seem fine the entire day and then suddenly arrest, document frequently
- Corrects errors while ensuring original information is visible / retrievable
- Ensures that documentation is completed by the individual who performed the action or observed event
Explain the principle of security in documentation
“Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures that are consistent with the standard(s) and legislation”
- Ensures confidentiality
- Personal Health Information Protection Act (PHIPA)
Describe the different methods and formats of documentation
- Flow sheets
- Narrative notes
- Problem-oriented charting (SOAP, SOAPIER)
- Focused charting (DAR)
- Charting by exception - ABCDs (airway, breathing, circulation and disability(neuro)), colour, sensation, swelling
- Chart the same for all patients, regardless of state
Provide example of SOAP note
- S (subject) – “my tummy really hurts today”
- O (object) – Child curled up in bed crying and c/o pain when moved to assess abdominal wound. Dressing saturated with purulent drainage. Temp 38.5° C.
- A (assessment) – At risk for wound infection
- P (plan)– Notify surgeon, administer Tylenol and monitor temp., reinforce dressing, monitor pain.
What is ADPIE
Assess, Diagnose, Plan, Implement, and Evaluation
Explain the Assessment step of the nursing process
Gathering, analysis, synthesis of collected data - Interview - Subjective data Symptoms - Physical assessment - Objective data Signs - Charts and medical records
Explain the Diagnosis step of the nursing process
- Process of analyzing and synthesizing the assessment data to determine the nursing problem(s)/issues
- Conclusion about an identified cluster of signs and symptoms
- Can be actual problems or potential (at risk for)
- Actual problem is written with PES, potential problem is written as PE and describe as “at risk for…”
What is PES
Problem (P): a brief statement of the patient’s potential or actual health problem (e.g., pain)
Etiology (E): a brief description of the probable cause of the problem; contributing or related factors (e.g., related to surgical incision, localized pressure, edema) – this is what it is related to ie/ might see secondary to, before related to
This nursing diagnosis is helpful because when talking to the doctor we are highlighting these things
Signs & Symptoms (S): a list of the subjective and objective data cluster that leads the nurse to pinpoint the problem; critical, major, or minor defining characteristics (e.g., as evidenced by verbalization of pain, isolation, withdrawal)
Explain the Planning step of the nursing process
Prioritization & Patient oucomes:
- Determine highest priority (ABC, Maslow’s hierarchy of needs, patient’s perception)
- Establish and develop “SMART” goals for treatment (may be short or long term)
Intervention:
- Any treatment based on sound knowledge, clinical judgment, decision making and research that the nurse performs to achieve established Goals (patient outcomes)
- Provide specific written instructions and an individualized approach to patient care – if everything is stable, want to see what is important to them
Explain the Implementation step of the nursing process
- Carry out the interventions indicated on the plan or designate them to others
- Communicate the plan of care to other members of the healthcare team
- Continually evaluate the effectiveness of methods chosen to implement plan
Explain the Evaluation step of the nursing process
- Evaluate patient’s response to nursing interventions and progress toward achieving goals / outcomes
- Review desired goals / outcomes, collect evaluation data, draw a conclusion, write an evaluative statement, revise goals and/or interventions as indicated
What is growth in children
- Quantitative change, measurable
- Includes physical changes in height, weight, dentition head and chest circumference
- Growth patterns & parameters
