Unit 6 - Documentation Flashcards
Documentation, whether written or electronic, should be:
FA Cx4
Factual
- words such as “appears” or “seems” usually precede a judgment and therefore are not acceptable
Accurate
- measurements, don’t use abbrevs.; date/sign all entries with name and designation; if late, write current date and time must be written and “late entry”
Complete
- see next card
Current
- written in timely fashion
Chronological
- describe observations, document actions
Compliant with applicable standards set out by regulatory bodies
- don’t erase/whiteout, black ink, don’t pre-chart, protect password
Complete assessment documentation will include: (4)
CACO
Complete health hx
Ax findings
- description of any foot pathologies
- ID risk factors for foot complications
Care plan based on the client’s needs, including:
o goals for tx
o client education
o referrals
Ongoing evaluation and modification of the care plan
After the assessment data is collected the foot care nurse can begin to develop a plan of care.
After analyzing the data the nurse has a better understanding of the client’s needs.
What are the next 3 steps?
use client input (gathered in ax process) to individualize plan
cluster data logically
generate nursing diagnoses
4 categories
Diagnosis - problem and etiology
Goals - SMART
Interventions
Evaluation
Common nursing diagnoses that may be applied to the lower limb include but are not limited to:
PII SHIR
piishir
pain
impaired skin integrity
impaired tissue profusion
self-care deficit
health seeking behaviour
ineffective health maintenance
risk factors for foot complications
When establishing a plan of care, and setting goals, the nurse should remember to:
(Memorize, like, 5)
forewarn the patient about procedures or interventions
teach skills to the patient
assist the decision-making process by offering choices
involve the family (provided confidentiality is not at issue)
reinforce appropriate behaviours
explain procedures and concepts in familiar and easily understood terms
discuss the plan of care, and do not dictate
advise the patient regarding the care plan and options
be willing to change or modify planned goals as the situation dictates.
The adult learner is characterized by:
Self-directed approach to learning
- choosing when/what/how to learn
Life experienced learning
- drawing on past experience to build new skills)
Social motivation
- a father may be motivated to improve his health for the sake of his children
Application of learned behaviours in an expedient manner
- short term goals are usually more effective when an opportunity to practice learned skills is given
After an assessment, the nurse will accurately document the findings.
The nurse then…?
shares observations with the client
After an assessment, the nurse will accurately document the findings.
The nurse then shares observations with the client and…?
together they devise a plan of care
With the client’s input throughout the assessment process is important to generating a care plan, because why?
the care plan will be individualized and focused on the areas the client deems as most important
SMART goals
Specific Measurable Achievable Realistic Timely
Example of diagnosis and goals
Patient is unable to care for his/her own feet Etiology Related to: poor vision weakness of hands lack of coordination inability to reach feet decreased mental alertness
Documentation provides…?
proof of the quality care that the foot care nurse has provided to the client
What should be documented?
Interventions
Client’s response
Plan
When should documentation occur?
directly after the foot care is provided
For the purposes of documentation, basic foot care is?
care that takes less than 35 minutes to complete
For the purposes of documentation, basic foot care is care that takes less than 35 minutes to complete. It consists of:
(
swabbing and cleansing the nails
cleaning and defining the nail edge
trimming the nails following the natural curve of the nail
filing rough edges until smooth
cleaning away loose detritus
filing and smoothing corns/calluses
applying emollients
client education
care plan
Extensive foot care is care that takes longer than 35 minutes to complete. It consists of…?
Everything included in basic foot care PLUS
work on problem nails o ingrown nails o fungal nails o thickened horny nails o poor quality nails r/t structural deformities
work on corns/calluses
What is a consultation?
when one health care professional formally seeks the advice of another health care professional
How can consultations occur?
A consultation can occur face to face, over the phone or through confidential email.
For example, a new foot care nurse may consult with an experienced foot care nurse when presented with extreme Ram’s Horn nails for the first time.
What is a referral?
an arrangement that is made to have a client receive services by another member of the foot health care team.
How does the nurse make a referral?
advise or assist the client to set up a visit with their family physician for further assessment and treatment
An example of a referral would be if a foot care nurse is performing care on a client with diabetes and observes a new open area on the foot.
What should accompany a referred client?
A written referral
What would the foot care nurse document in a written referral?
brief and concise background info
(name, age, history r/t reason for referral)
pertinent assessment information
current nursing interventions or treatments
foot care nurse’s full name, signature and contact information
Both consultations and referrals must be…?
documented in the client’s chart
Guidelines for Writing a Complete Nursing Care Plan
3 re. the NCP Include (1) Headings Dates (2) Each visit (2)
the NCP should be individualized to suit the client
the NCP can be standardized and preprinted as long as they can be individualized to suit the client
the NCP should be organized and clear.
Any foot care nurse should be able to read the plan and quickly understand what the client’s needs are
Include collaborative interventions such as referrals to other members of the foot health care team
use headings such as: Nursing Diagnosis, Goals/Outcomes, Interventions, Evaluation
evaluation dates must be clearly written
all NCP must be dated and signed
NCP must be referred to and updated at each visit
Nursing Dx
Grooming Self Care Deficit r/t decreased visual acuity & musculoskeletal impairment of hands AEB client statement “I can’t see my toenails to cut them” & limited strength and ROM in both hands
Goals/Outcomes
The client’s feet will be groomed regularly AEB trimmed toenails and reduced calluses
by October 14, 2008.
Signature & today’s date
Intervx
- Foot care nurse to visit q 6 weeks
- Assess the client’s ability for self care
- Assess lower limb and feet
- Trim toenails
- Reduce calluses
- Refer to pedorthist for foot wear to off load pressure
