SKILLS LECTURE 4 Flashcards
OXYGEN SATURATION
MEASURES THE % OF HEMOGLOBIN THAT IS SATURATED WITH OXYGEN
HOW IS OXYGEN DELIVERED TO THE PATIENT?
WALL OXYGEN
PORTABLE OXYGEN TANK
OXYGEN CONCENTRATOR
NEBULIZED MIST TREATMENTS
DEVICES USED TO ADMINISTER NEBULIZER MIST TREATMENTS
WALL OXYGEN
CONCENTRATOR
NEBULIZER
HOW MANY LITERS PER MINUTE WOULD YOU SET OXYGEN FOR A NMT?
6-8L/MIN
WHAT DOES CPAP STAND FOR?
Continuous Positive Airway Pressure
WHAT DOES BIPAP STAND FOR?
Bilevel Positive Airway Pressure
WHAT WILL REDUCE DATA ENTRY ERRORS?
DOCUMENTING PROMPTLY
what is one of the best defenses for legal claims
accuracy in documentation
What Clarifies treatment rendered?
Reimbursement
What Improves quality of care
auditing and monitoring
what helps anticipate care needed for the patient
education
what contributes to evidenced based practice
research
HIPAA
Health Insurance Portability and Accountability Act
RULES OF HIPAA
The patient’s privacy must be protected from anyone not on the health care team
The patient has a right to his or her medical information
The patient must give permission for family/loved ones to have access to any medical data
Patient’s can give verbal permission for a family member at the bedside to get information while they are present on any occasion
You must ask if it is okay to speak in front of visitors before you begin doing anything with the patient
Treatment info can be shared so that insurance companies can examine charges appropriately
WHAT POSITION SHOULD YOU PUT PATIENT IN IF THEY ARE HAVING TROUBLE BREATHING?
FOWLERS OR TRIPOD
WHEN SHOULD OXYGEN BE APPLIED?
During acute disturbance in oxygen status
O2 sats lower than patient’s baseline
RR elevated >20 BECAUSE WE ARE NOT OBTAINING ALL GASSES AFFECTIVELY
SOB
accessory muscle use
Decreased mental status
WHAT DOES TITRATE MEAN
ADJUST OXYGEN
METHODS OF DOCUMENTATION
narrative charting
flow sheets
progress notes
charting by exception
NARRATIVE CHARTING
Recording of all patient information, assessment data, care, interventions, etc.
Traditional method, Story-like method
Free text entry
FLOW SHEETS
Graphic records, organized by body system
Facilitate documentation of routine, repetitive care
If there is a change in patient status, you must expand documentation of routine care and assessments
PROGRESS NOTE
Narrative charting that is used when additional information needs to be discussed in the chart from the flowsheet
CHARTING BY EXCEPTION
Includes standards of normal assessment findings and routine care
If there is an exception to the normal assessment finding, the nurse must discuss it in the attached narrative charting, in detail
WHAT WE USE IN NURSING SCHOOL
NARRATIVE NOTE
Writer freely documents information obtained from assessment, interventions performed, etc
FOCUSED CHARTING
D-A-R Format
Data
Action
Response
FACTUAL WHEN DOCUMENTING
Clear, descriptive objective information about what the nurse observes, hears, palpates, smells
Avoid vague terms (appears, seems, apparently)
No opinions
ACCURATE DOCUMENTATING
Specific information with as much detail as possible
Not correct: Large abdominal incision healing well
Correct: Open wound on abdomen, midline, 5cm in length, 1cm wide, without redness, drainage or edema
CURRENT ON DOCUMENTATION
Ensure entries are timely
Avoid delays in documentation as much as possible! Chart as you go
Use 24 hour time, always
ORGANIZED WHEN DOCUMENTING
Notes should be clear, concise, to the point, in a logical order
If you are documenting about a complex situation; think about the situation that occurred, the order in which it occurred, and the words you want to use to describe it. Then begin charting.
COMPLETE WHEN DOCUMENTING
Ensure all information is present before you leave
DOCUMENT THE FOLLOWING WHEN GETTING A VERBAL ORDER
verbal order given, that you provided a read back, and the provider approved
IF A PATIENTS O2 DROPS WHEN EXERCISING WHAT DO WE NEED TO DO
ASSESS AND COUNT RESPIRATIONS AND CHARACTERISTICS OF RESPIRATIONS
WHERE CAN YOU ASSESS O2
FINGER
TOES
FOOT
FOREHEAD
EARLOBE
MAKE SURE THE SITE OF WHERE O2 IS BEING ASSESSED IS WHAT
APPROPRIATE TO SITUATION
WHAT IF THE READ IS LESS THAN 94%?
ASK YOURSELF IF READING IS TRUE
HAS THE PULSE OX BEEN ON THE FINGER LONG ENOUGH
IS THE EXTREMITY COLD
DO I NEED TO TRY ANOTHER DIGIT
WHAT ALL DO YOU ASSESS IF AN O2 READING IS BELOW 94%?
INSPECTION
ASK SUBJECTIVE QUESTIONS
LUNG SOUNDS
RECALL PATIENT HISTORY
WHAT DO YOU INSPECT ON AN ASSESSMENT IF O2 IS LOW
RESPIRATORY RATE, PATTERN AND EFFORT
COLOR OF LIPS
ACCESSORY MUSCLE USE?
CHEST SYMMETRICAL DURING EXPANISION?
SUBJECTIVE QUESTIONS YOU WILL ASK WHEN O2 IS LOW
FEELING SOB?
DYSPNEA?
DOES PT KNOW NORMAL O2 RANGE?
MENTAL STATUS
IS PT SPEAKING IN COMPLETE SENTENCES WHEN THEY TALK TO YOU
MENTAL STATUS APPROPRIATE TO PTS BASELINE?
WHAT POSITION SHOULD YOU HAVE PATIENT IN IF YOU NOTICE O2 IS LOW?
HIGH FOWLERS OR TRIPOD
IF PATIENT HAS LOW OXYGEN ENCOURAGE WHAT?
COUGHING AND DEEP BREATHING
IF PATIENTS O2 RATE IMPROVED WITH HIGH FOWLERS AND DEEP BREATHING WHAT IS THE NEXT STEP?
NOTIFY THE INSTRUCTOR OF YOUR ASSESSMENT AND INTERVENTIONS
IF PATIENTS O2 RATE IS NOT IMPROVED WITH HIGH FOWLERS AND DEEP BREATHING WHAT IS THE NEXT STEP?
Do not leave the patient, call for assistance or wheel the patient to the nurse’s station
CHECK TO SEE IF THEY NEED OXYGEN OR NEBULIZER TREATMENT
IF THERES AN O2 ORDER WHAT DOES IT SAY AND APPLY O2 IF APPROPRIATE
CHECK IF THERE IS PRN MEDICATIONS ORDERED
APPLY OXYGEN IF INTERVENTIONS DONT WORK EVEN WITHOUT AN ORDER
REASSESS AFTER INTERVENTIONS IMPLEMENTED
REPORT CHANGES
DOCUMENT
REASSES O2 AND RESPIRATORY ASSESSMENT MULTIPLE TIMES
NEVER LEAVE THE PTS SIDE IF THE O2 IS LESS THAN WHAT?
90%
WHAT DOES DAR STAND FOR?
DATE
ACTION
RESPONSE
WHAT ARE YOU DOCUMENTING WHEN AN O2 IS OUT OF NORMAL RANGE?
PTS SPO2 AND FULL INITIAL ASSESSMENT
DOCUMENT INTERVENTIONS PERFORMED, THE PATIENTS REPSONSE AND YOUR ASSESSMENT AFTER
DOCUMENT ALL INFO YOU REPORTED TO THE INSTRUCTOR
ROOM AIR IS A MIXTURE OF WHAT
OXYGEN
NITROGEN
CARBON DIOXIDE
ECT
WHAT IS THE OXYGEN CONCENTRATION IN ROOM AIR?
TYPICALLY ABOUT 21%
What affects oxygenation?
Physiological factors
Developmental factors
Lifestyle factors - SMOKING
Environmental factors – POLLUTION, SECOND HAND SMOKE
SUPPLEMENTAL OXYGEN IS CONSIDERED A
MEDICATION
When should oxygen be applied?
RR elevated >20 BECAUSE WE ARE NOT OBTAINING ALL GASSES AFFECTIVELY
SOB
accessory muscle use
Decreased mental status
OXYGEN RANGE ORDERS ARE ________ TO EACH PT
INDIVIDUALIZED
THINGS TO AVOID WHEN WEARING OXYGEN
FIRE/SMOKING
LUBRICANTS
PETROLEUM JELLY
WHAT IS THE TYPICAL DOSE OF OXYGEN WITH NASAL CANNULA
2L/MIN
WHAT IS THE AMOUNT OF OXYGEN ONE CAN USE WITH A NASAL CANNULA
0.1-6 LITERS A MINUTE
WHAT IS THE TYPICAL AMOUNT OF OXYGEN GIVEN WITH A HIGH FLOW NASAL CANNULA?
6-15
what is the amount of oxygen delivered with a high flow nasal cannula
up to 60 liters of oxygen
what is a high flow nasal cannula used to treat?
acute respiratory distress
-can be used in chronic patients who require higher flow rates than a nasal cannula
the amount of oxygen that can be delivered with a simple face mask
5 - 10 liter per minute
how much oxygen does a simple face mask deliver?
40%-40%
does not have a precise amount of oxygen concentration it give
when do you give a non-rebreather mask (NRB)
when a patient needs 15+ liters
THE AMOUNT OF OXYGEN DELIVERED WITH A NON-REBREATHER MASK
UP TO 15 LITERS PER MINUTE
HOW MUCH OXYGEN DOES A NON-REBREATHER MASK DELIVER TO A PERSON
100% OXYGEN CONCENTRATE
Side vents on mask are one-way valves; allowing exhaled breath to exit ______, but only allowing patient to breath in _____ from bag (prevents breathing in room air)
CO2
OXYGEN
WHAT IS USED WHEN A PATIENT IS IN RESPIRATORY DISTRESS AND/OR REQUIRES HYPEROXYGENATION?
NON-REBREATHER MASK
YOU CAN USE A NON-REBREATHER MASK THAT IS NOT CONNECTED TO OXYGEN FOR WHAT KIND OF PATIENT AND WHY?
ONE THAT IS HYPERVENTILATING SO THEY CAN GET THE CO2 BACK IN THEIR BODY FOR EVEN GAS EXCHANGES
WHAT PREVENTS HYPERVENTILATING?
DEEP BREATHING
PURSED LIPPED BREATHING
WHAT DEVICES CAN BE USED WITH HUMIDIFICATION
WALL OXYGEN
OXYGEN CONCENTRATOR
HOW DO YOU CHOOSE THE APPRIORTIATE OXYGEN DEVICE?
BY THE AMOUNT OF OXYGEN THE PATIENT NEEDS AND THEIR CONDITION
HOW OFTEN DOES OXYGEN TUBING GET CHANGED
WHEN IT GETS DIRTY NO SPECIFIC TIME FRAME
WHAT KIND OF OXYGEN DEVICE WILL YOU SEE IN A STABLE SETTING OR LONG TERM CARE SETTING?
NASAL CANNULA
FACE MASK (NEB TX ONLY)
IF A PATIENT IS IN A HOME SETTING AND NEEDS A HIGHER LEVEL OF OXYGEN THAN A NASAL CANNULA OR MASK CAN DELIVER WHAT NEEDS TO BE DONE?
PATIENT NEEDS TO BE TRANSFERRED TO A HIGHER LEVEL OF CARE LIKE THE HOSPITAL
PATIENTS REQUIRING NON-REBREATHERS OR HIGH FLOW OXYGEN ARE MOST LIKELY IN WHAT CARE SETTING?
ACUTE DUE TO RESPIRATORY DISTRESS
HOW IS OXYGEN DELIVERED TO THE PATIENT?
WALL OXYGEN
PORTABLE OXYGEN TANK
OXYGEN CONCENTRATOR
HOW IS WALL OXYGEN SET UP?
OXYGEN FLOWMETER IS ATTACHED TO THE WALL
CONNECTED TO MAIN SOURCE OF OXYGEN IN THE BUILDING
NEVER RUNS OUT
USE THE DIAL AND FLOATING BALL TO TITRATE THE AMOUNT OF OXYGEN DELIVERED TO THE PT
WHERE IS WALL OXYGEN TYPICALLY USED
MAINLY HOSPITAL SETTINGS
SOMETIMES AT NURSING HOMES
HOW IS A PORTABLE OXYGEN TANK USED
A SPECIFIC AMOUNT OF PRESSURIZED & COMPRESSED OXYGEN COMES IN TANK
A REGULATOR MUST BE USED WITH TANK AND TELLS YOU HOW MUCH OXYGEN IS IN THE TANK
THE DIAL ON THE LEFT IS USED TO TITRATE THE AMOUNT OF OXYGEN BEING DELIVERED TO THE PT
CAN YOU USE HUMIDIFICATION WITH A PORTABLE OXYGEN TANK
NO
HOW IS OXYGEN DELIVERED TO A PATIENT WHEN USING A OXYGEN CONCENTRATOR
MACHINE PULLS ROOM AIR INTO THE DEVICE
MACHINE THEN PURIFIES THE O2 AND REMOVES THE OTHER PARTS OF THE ROOM AIR
DELIVERS PURIFIED AIR AT A SPECIFIC RATE
NEVER RUNS OUT OF OXYGEN
MUST BE PLUGGED IN TO THE WALL AND TURNED ON
CAN O2 FROM AN OXYGEN CONCENTRATOR BE HUMIDFIABLE?
YES
WHAT ARE NEBULIZED MIST TREATMENTS USED FOR?
TO ADMINISTER MEDS DIRECTLY TO THE LUNGS
WHAT IS THE MOST COMMON MEDICATION ADMINISTERED WITH A NEBULIZED MIST TREATMENT?
ADRENERGIC BRONCHODILATOR
HANDHELD DEVICE OR SIMPLE FACE MASK
TWO THINGS PATIENTS USE TO GET NMT
OXYGEN DELIVERY DEVICES USED TO ADMINISTER NMT:
NEBULIZER MACHINE
WALL OXYGEN OR AIR
WHAT MUST YOU DOCUMENT WHEN ADMINSTERING A NEBULIZED MIST TREATMENT?
VITALS
FOCUSED RESPIRATORY RATE
MENTAL STATUS
ASCULATE LUNG SOUNDS FRONT AND BACK X5
SHOULD ASSESS PRE-TREATMENT AND POST TREATMENT
HOW LONG AFTER NMT SHOULD YOU REASSES?
15-20 MINUTES AFTER IT IS DONE TO VALIDATE THE INTERVENTIONS WE DID
WHAT DOES CPAP STAND FOR?
CONTINUOUS POSITIVE AIRWAY PRESSURE
WHAT DOES BIPAP STAND FOR?
BILEVEL POSITIVE AIRWAY PRESSURE
WHAT ARE BIPAP AND CPAPS USED FOR
AID IN BREATHINGWHILE ASLEEP WITH PATIENTS WITH SLEEP APNEA, COPD OR OBESE
CPAP AND BIPAP CAN BE USED IF PATIENT IS IN RESPIRATORY DISTRESS AS A STEP BEFORE WHAT OTHER INTERVENTIONS?
INTUBATION
MECHANICAL VENTILATION
WHAT IS AN INVASIVE PROCEDURE THAT IS USED FOR A SHORT-TERM INTERVENTION FOR RESPIRATORY DISTRESS?
INTUBATION
IF A PATIENT NEEDS LONG-TERM VENTILATOR SUPPORT WHAT WILL BE PLACED?
TRACHEOSTOMY TUBE
HOW IS A PT INTUBATED?
The patient is first sedated and paralyzed, then an endotracheal (ET) tube inserted into the mouth, down the throat and into the trachea
A machine (ventilator) is connected to the end of the ET tube to assist in ventilation
Ventilators are machines that provide what
oxygenation and ventilation (respirations)
when is a mechanical ventilation used?
when a patient is unable to effectively breathe on their own
Uses positive pressure to push oxygenated air into the lungs
ventilator
what are the nursing documentation systems?
paper
ehr
is sleeping subjective or objective
subjective
if you document promptly what can this reduce?
data entry errors
The quality of patient care depends on your ability to:
communicate with other members of the healthcare team
what can miscommunication between healthcare providers cause?
care becomes fragmented
tasks are repeated
delays or omissions in care can occur
make sure you are painting a clear picture when documenting in the chart so that:
others will know exactly what you are saying without any verbal communication
what is an electronic health record?
integrates all pt info into one record all visits and admissions
what is an electronic medical record?
a record within an individual visit or admission
Experts believe that implementing electronic health records (EHRs) across the health care delivery system will decrease what? and improve what?
cost
improve the quality of care
nurses are legally and ethically obligated to:
keep all patient info confidential
who can a nurse share patient status with?
only the members of the health care team
Information regarding a patient’s health status may not be released to non–health care team members because:
A. legal and ethical obligations require health care providers to keep information strictly confidential.
B. regulations require health care institutions to document evidence of physical and emotional well-being.
C. reimbursement issues related to patient care and procedures may be of concern.
D. fragmentation of nursing and medical care procedures may be identified.
A. legal and ethical obligations require health care providers to keep info strictly confidential
Privacy, Confidentiality, and Security Mechanisms with electronic records
electronic documentation has legal risks
use of logical and physical restrictions to protect info
each individual has a specific username and password
place computers or file servers in restricted areas or use privacy filters for computer screens visible to others
HOW CAN YOU PROTECT PT INFO ON PRINTED DOCUMENTS?
DESTROY WHEN NO LONGER NEEDED
DE-IDENTIFY ALL PATIENT DATA
HOW DO YOU SIGN EVERY ENTRY OF DOCUMENTATION AS THE STUDENT NURSE?
FIRST AND LAST NAME AND SN (STUDENT NURSE)
Guidelines for Quality Documentation
FACTUAL
ACCURATE
CURRENT
ORGANIZED
COMPLETE
FACTUAL INFO WHEN DOCUMENT INCLUDES
-CLEAR DESCRIPTIVE OBJECTIVE INFORMATION ABOUT WHAT THE NURSE OBSERVES, HEARS, PALPATES, SMELLS
-AVOID VAGUE TERMS
-NO OPINIONS
ACCURATE INFO WHEN DOCUMENT INCLUDES
SPECIFIC INFO WITH AS MUCH DETAIL AS POSSIBLE
CURRENT INFO WHEN DOCUMENT INCLUDES
-ENSURE ENTRIES ARE TIMELY
-AVOID DELAY IN DOCUMENTATION AS MUCH AS POSSIBLE CHART AS YOU GO
-USE 24 HOUR TIME ALWAYS
ORGANIZED INFO WHEN DOCUMENT INCLUDES
NOTES SHOULD BE CLEAR,CONCISE, TO THE POINT, IN LOGICAL ORDER
-IF YOU ARE DOCUMENTING ABOUT A COMPLEX SITUATION, THINK ABOUT THE SITUATION THAT OCCURED, THE ORDER IN WHICH IT OCCURED, AND THE WORDS YOU WANT TO USE TO DESCRIBE IT. THEN BEGIN CHARTING
COMPLETE INFO WHEN DOCUMENT INCLUDES
ENSURE ALL INFO IS PRESENT BEFORE YOU LEAVE
RULES OF DOCUMENTATION
-ALL DOCUMENTATION ENTRIES MUST HAVE A DATE AND TIME
-THE AUTHOR OF THE ENTRY MUST BE CLEARLY IDENTIFIED
-SIGN FULL NAME WITH CRENDITIALS
-CORRECT SPELLING IS IMPERATIVE
Narrative documentation rules
-ALWAYS CAHRT WHEN YOU RECEIVE REPORT FROM ANOTHER INDIVIDUAL AND INCLUDE THEIR NAME AND CREDENTIALS
-ALWAYS CHART WHEN YOU RELINQUISH CARE AND PROVIDE REPORT TO ANOTHER INDIVIDUAL
-ALWAYS CHART WHEN YOU ASSUME CARE OF THE INDIVIDUAL. INCLUDE AGE,SEX, HOW YOU IDENTIFIED THE PT (2 IDENTIFIERS) AND WHAT YOU VERIFEID THIS INFO AGAINST
WHEN YOU HAVE AN ABNORMAL FINDING YOU NEED TO DO WHAT KIND OF CHARTING?
NARRATIVE CHARTING
WHAT SHOULD YOU CHART WHEN NARRATIVE CHARTING?
PATIENT COMPLAINTS
NURSING INTERVENTIONS
REASSESSMENTS
CHANGE IN PT STATUS WITH SUPPORTIVE DETAILS/ASSESSMENT, NURSING RESPONSE, WHAT YOU DID FOR THE PATIENT
EDUCATION PROVIDED
PATIENT RESPONSE TO EDUCATION
PATIENTS REFUSAL - DOCUMENT EDUCATION AND REFUSAL
NURSES REPONSE TO PTS REFUSAL
INFO COMMUNICATED TO OTHERS
WHEN REPORTING FINDINGS TO A PROVIDER WHAT NEEDS TO BE DOCUMENTED?
THAT YOU HAVE NOTIFIED THE PROVIDER OF THE PATIENTS FINDING AND THEIR REPONSE/FOLLOW
HOW OFTEN SHOULD YOU DOCUMENT WHEN YOU MAKE A PHONE CALL TO A PROVIDER?
EVERY TIME
TELEPHONE AND VERBAL ORDER DOCUMENTATION
ONLY USE VO IF ITS AN EMERGENT SITUATION
IF YOU GET A VO READ IT BACK TO THE PROVIDER TO CONFIRM IT
DOCUMENT THE FOLLOWING: VERBAL ORDER GIVEN, THAT YOU PROVIDED A READ BACK AND THE PROVIDER APPROVED
WHAT SHOULD YOU NOT ADD WHEN USING NARRATIVE DOCUMENTATION
PERSONAL OPINIONS
SUBJECTIVE INFO WITHOUT QUOTATIONS
SUBJECTIVE TERMS OR JUDGEMENTS
IDENTIFYING INFO
Handwritten charting rules
Start each new entry with the full date (month/date/year), time (24 hour time), and end the entry with fully signature and title
End your entry with your legible signature and title at the far right end of the line
Sign at the end of each page of charting
Even if you aren’t finished with the specific note, you must sign out the page so the entry is valid – if you don’t sign it it didn’t happen
Do not use white-out
Write within the lines provided
Do not leave blank spaces between your written information and signature
Use a straight horizontal line between the end of your writing and your signature
Write legibly in permanent black ink
If an error isn’t identified until after the entry is written and signed out how would you correct it
Cross out the entire sentence with the error in it
Create a late entry and rewrite the sentence with the appropriate information
documenting late entries
If the nurse forgot to chart a specific piece of information during a specific time, a late entry may be made.
Enter the current date and current time
Identify that the entry is a late entry, identify the time the late entry correlates with
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of:
A. PIE documentation.
B. SOAP documentation.
C. narrative charting.
D. charting by exception.
c narrative charting
A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record:
A. an interpretation of patient behavior.
B. objective data that are observed.
C. lengthy entry using lay terminology.
D. abbreviations familiar to the nurse.
b. objective data that are observed
A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to:
aid in the hospitals quality improvement program
