Module 1 Flashcards
Why are observations and documentation important elements of nursing care in the acute care patient?
Vital sign assessment is essential to determine the pt’s health status.
Documentation improves communication, promotes good nursing care & meets professional and legal standards.
Nurses communicate their observations, decisions, actions & outcomes of actions for pts via documentation.
It is an accurate account of what occurred and when it occurred.
Why do we do observations in acute care pts?
An alteration in a pt’s vital signs can provide objective evidence of the body’s response to physical & psychological stress, or changes in physiological function.
Why is it important to know the normal limits of TPR, BP and O2 sats?
Careful measurement techniques & knowledge of the normal range in vital signs for the particular pt ensures the pt is suitably monitored to enable clinicians to carefully monitor therapy & prevent adverse effects.
What do we do with the results when we have recorded them?
Compare to previous results.
Determine if in normal limits.
If outside expected limits, check to see if pt has a modification to the AORC in place. If not, escalate as per protocol.
What are the main causes of mortality and morbidity among Australian adults?
Australia 2013:
Ichaemic heart disease Dementia Alzheimer's Disease CVD Trachea/bronchus/lung cancer Chronic lower respiratory disease Diabetes Colon cancer Blood & lymph cancer Leukemia Heart failure Prostate cancer
What are some of the legal issues you have hear of regarding documentation in nursing?
Poor documentation can result in being sued for negligence.
Failure to use non-judgmental terminology may lead to libel suit if records are accessed under Freedom of Information.
Gaps in medical records allows someone else to ‘fill in the blanks’ or tell a different story.
Failure to follow documentation policy of the organisation can result in the organisation not responsible for providing legal support in the event of litigation.
Nursing diagnoses mostly differ from medical diagnoses in that they are:
Primarily concerned with caring, while medical diagnoses are primarily concerned with curing.
