Unit III Flashcards
1
Q
purpose of the nursing process
A
- guide to caring for the client
- provide continuity of care from all nurses
- scientific problem solving method
- EBP (evidenced based practice)
- challenge you
- gather, interpret, and drive nursing judgements
2
Q
EBP
A
evidenced based practice
3
Q
nursing process
A
-approach on great quality care
-an organization framework for professional nursing practice
an ongoing, multidimensional, cyclic approach in which data are collected, critically analyzed and incorporated into the client’s treatment plan in accordance with the client’s fluctuating responses to health and illness
*as your patient makes progress you have to adjust treatment plan
-a critical thinking compentency that allows nurses to make judgments and take actions based on reason
-identifying, diagnosing, and treating human responses to health and illness
4
Q
health perception-health management pattern
A
- describes the patient’s self-report of health and well-being
- how health is managed (ex. frequency of physician visits, adherence to prescribed therapies at home)
- knowledge of preventitive health practices
5
Q
nutritional-metabolic pattern
A
describes the patient’s daily/weekly pattern of food and fluid intake (ex. food preferences, special diet, food restrictions, appetite)
- actual weight
- weight loss or gain
6
Q
elimination pattern
A
describes patterns of excretory function (ex. bowel, bladder, and skin)
7
Q
activity-exercise pattern
A
- describes the patterns of exercise, activity, leisure, and recreation
- ability to perform activities of daily living
8
Q
sleep-rest pattern
A
describes patterns of sleep, rest, and relaxation
9
Q
cognitive-perceptual pattern
A
- describes sensory-perceptual patterns
- language adequacy
- memory
- decision-making ability
10
Q
self-perception- self concept pattern
A
describes the patient’s self-concept pattern and perceptions of self (ex. self-concept/worth, emotional patterns, bosy image)
11
Q
role-relationship pattern
A
describes the patient’s pattern of role engagements and relationships
12
Q
sexualty-reproductive pattern
A
- describes the patient’s patterns of satisfaction and dissatisfaction with sexualty pattern
- patient’s reproductive pattern
- premenopausal and postmenopausal problems
13
Q
coping-stress-tolerance pattern
A
describes the patient’s ability to manage stress
- sources of support
- effectiveness of the pattern in terms of stress tolerance
14
Q
value-belief pattern
A
describes patterns of values, beliefs (including spiritual practices), and goals that guide the patient’s choices and decisions
15
Q
analyze data related to functional health patterns
A
- organization of data
- general to specific
- determine the client’s health issues
16
Q
five steps of the nursing process
A
- assessment
- diagnosis
- nursing diagnosis - planning/outcomes
- implementation
- interventions
- take action to help patients reach their outcomes - evaluation
- did my patient reach my expected outcome?
17
Q
assessment
A
- step 1 in nursing process
- gather, verify, and communicate data about patient so that database is established
18
Q
diagnosis
A
- step 2 in nursing process
- medical
- nursing
19
Q
planning
A
step 3 in nursing process
- to identify patient’s goals
- determine priorities of care
- determine expected outcomes
- design nursing strategies to achieve goals of care
20
Q
implementation
A
- step 4 in nursing process
- interventions
- take action to help patients reach their outcomes
- carry out nursing actions necessary for accomplishing plan of care
21
Q
evaluation
A
- step 5 in nursing process
- did my patient reach my expected outcome?
- to determine extent to which interventions helped achieve goals of care
22
Q
purposes of nursing assessment
A
- establish a database about the client’s perceived needs, health problems and responses to those problems
- gather, verify and communicate data about the client
- to identify pertinent experiences, health practices, values, lifestyle and expectations of the health care system
- validate information is current
23
Q
primary source
A
collect patient data
24
Q
secondary source
A
- family
- health care record
25
subjective data
- the patient
- client's perceptions about their health problems
- feelings of mental or physical distress
- difficult to measure
* pain
* anxiety
26
objective data
- observations or measurement made by the nurse or another staff member
- bassed on accepted standards
* lab values, diagnostic results
* observations of behavior
* information from medical record
- does not include interpretive statements
* "I think she's pretty confused."
* "Patient is nice."
- needs to be descriptive, concise, complete
* "Client does not know her name, the date or where she is."
* "Client is cooperative with the interview process."
27
physical assessment skills
1. inspection
2. auscultation
3. palpation
4. percussion
5. olfaction
28
inspection
- careful, critical observation
- inspect for size, shape, color, symmetry, position and abnormalities
- compare to opposite side when possible
- need to know normal to identify abnormal
29
auscultation
- listening with a stethoscope to:
* cardiovascular system
* respiratory tract
* gastrointestinal tract
30
cardiovascular system
heart
31
respiratory tract
lungs
32
gastrointestinal tract
bowel sounds
33
palpation
- touching, feeling of body:
* skin
* organs
34
percussion
- tapping and listening
- listen to character of sound
* hollow
* solid
- be sensitive to patient's condition
* injury
35
olfaction
- odor
- identify nature and source of smells
- recognize odors that are characteristics of some disorders
36
vital signs
1. blood pressure
2. temperature
3. pulse
4. respirations
5. pain
37
blood pressure
- the force exerted on walls of an artery created by pulsing blood under pressure from heart
- systolic
* maxuimum pressure
* normal: less than 120
* blood is forced from heart
- diastolic
* lowest pressure at all times
* normal:less than 80
* relaxation
38
systolic
- maximum pressure
- normal: less than 120
- blood is forced from heart
39
diastolic
- lowest pressure at all times
- normal: less than 80
- relaxation
40
systolic prehypertension
120-139
41
hypotension
- systolic is 90 or below
- decreased blood or volume
- decreased cardiac output
42
hypertension
systolic is above 120-139 (prehypertension)
43
stage 1 hypertension: systolic
140-159
44
stage 1 hypertension: diastolic
90-99
45
stage 2 hypertension: systolic
greater than 160
46
stage 2 hypertension: diastolic
greater than 100
47
normal temperature
- 98.6
| - 36 to 38 C
48
oral temperature
98.6
49
aural temperature
- 98.6
| - ear
50
axillary temperature
- 97.7 (-0.9)
| - armpit
51
rectal temperature
99.5 (+0.9)
52
temperature
stored at hypothalamus
53
aural
ear
54
axillary
armpit
55
fever
abnormal elevation of temperature
56
febrile
have a fever
57
afebrile
without a fever
58
hypopyrexia
abnormally high body temperature
59
heat exhaustion
loss of fluids and electrolytes because exposed to high temperature
60
heat stroke
- body fails to regulate temperature
| - inability to regulate temperature
61
hypothermia
extremely low body temperature
62
pulse
- rhythm
- regular
- irregular
63
pulse rate
60-100 bmp
64
if abnormal pulse
do apical
65
fast pulse
tachycardia
66
slow pulse
bradycardia
67
strenght pulse
- strong
- weak
- thready
- bounding
68
pulse sites
- radial
- brachial
- corrotid
- temporal
- pedo pulse
69
respirations
exchange of gases between atmosphere and body
70
normal respirations
12-20 breaths per minute
71
fast respirations
tachypnea
72
slow respirations
bradypnea
73
rhythm respirations
regular or irregular
74
ventilation
movement of air in and out of the lungs
75
pain
- 5th vital sign
- onset and duration
- location
- whatever the patient says it is
76
quality of pain
- sharp
- dull
- crushing
- stabbing
- radiating
77
how severe the pain is
pain scales
78
pulse oximetry
- vital sign
- measures oxygen saturation
- be 90 or greater
79
pulse oximetry measurements influences
- oxygen therapy
- respiratory rate
- hypotension
- hemoglobin level
- medications
- body temperature
80
hyperventilation
increased volume of respirations
81
apnea
- not breathing
| - temporary sesation of breathing
82
dyspnea
shortness of breath
83
hypercarbia
high CO2
84
hypoventilation
decreased in rate and depth of respirations
85
hypernea
increased in respirations after working out or doing something strenous
86
health history
use of systems like Functional Health Patterns
87
reasons for seeking health care
- goals of care
- expectation of the services and care delivered
- expectations of the health care system
88
present illness or health concern
- onset
- symptoms,
- nature of symptoms (ex. sudden or gradual)
- duration
- percipitating factors
- relief measures
- weight loss or gain
89
health history
- prior illnesses throughout development
- injuries and hospitalizations
- surgeries
- blood transfusions
- allergies
- immunizations
- habits (ex. smoking, caffeine intake, alcohol or drug abuse)
- prescribed and self-prescribed medications
- work habits
- relaxation activities
- sleep
- exercise
- eating or nutritional patterns
90
family history
- health status of the immediate family and living relatives
- cause of death of relatives
- risk factor analyses:
* cancer
* heart disease
* diabetes
* mellitus
* kidney disease
* hypertension
* mental disorders
91
environmental history
- hazards
- pollutants
- physical safety
92
psychosocial and cultural history
- primary language
- cultural group
- community resources
- mood
- attention span
- developmental stage
93
review of systems
- head-to-toe review of all major body systems
- patient's knowledge of and compliance with health care (ex. frequency of breast or testicular self-examination or last visual acuity examination
94
sources of information for assessment
- patient
- family/significant other
- chart
- test/results/lab values
- other staff
95
normal values for lab results: WBC
5,000-10,000/mm^3
96
normal values for lab results for men: RBC
4.7-6.1 x 10^6
97
normal values for lab results for women: RBC
4.2-5.4
98
normal values for lab results for men: Hbg
14.018 gm/dl
99
normal values for lab results for women: Hbg
12.0-16.0 gm/dl
100
normal values for lab results for men: Hct
42-52%
101
normal values for lab results for women: Hct
37-47%
102
leukocytosis
elevated WBCs
103
leukopnea
low WBCs
104
other test results
- X-ray
- MRI
- CT
- ultrasound
- blood glucose
105
medical diagnosis
- identification, treatment and cure of a disease, or pathological process
- physicians treat illness
106
nursing diagnosis
- identification of a client's actual or potential response to a health problem
- nurses treat the client's response to illness
- to examine patient data to identify their health care needs to formulate nursing diagnoses
107
nursing diagnoses
- formal statements of an actual or potential response to a health problem
- result from collecting and analyzing data (assessment) and identifying responses; naming the condition reflected by the responses
108
nursing diagnoses part 1
- diagnostic statement:
* the actual or potential client response to health problem
1. P=problem
- after determining problem from assessment data, select an appropriate diagnosis from NANDA list
109
diagnostic statement
the actual or potential client response to health problem
110
P=
problem
111
NANDA
- North American Nusing Diagnosis Association, Dr. Marjory Gordon, FAAN
- 1973
- to assist nurses by developing a recognized taxonomy of diagnoses that would be universally understood by nurses
- updated every 2 years by NANDA
112
etiology
-also known as the the "related to" phrase
-what is causing or contributing to the nursing diagnosis?
-written: r/t
-must be within the domain of the nurse to treat, alon or in collaboration with team
-must be amenable to change through nursing action
-can be psychologic, biologic, relational, environmental, sexual, spiritual, situational, development or sociocultural
-it is not advisable to use medical diagnoses, because they are not usually amenable to change through nursing actions alone
-think in terms of the causes of illness that CAN be modified or affected by nursing care
-sometimes nursing and medical diagnoses are the same, but only if nursing can effect a change
exs.
-anxiety
-diarrhea
-constipation
113
E=
etiology
114
appropriate etiology
- medication side effects
- no fluid intake for 48 hours
- no bowel movement for 72 hours
115
characteristics
- nursing diagnoses part 3
- signs and symptoms the nurse has gathered during assessment
* phrased as "evidenced by" or AEB
* s=signs or symptoms
- observable, measureable manifestations of the client's response to the identifies health problem
- may be behaviors, signs, responses to illness/situation, expression of feelings
116
s=
signs and symptoms
117
diagnostic statement examples (PES)
- caregiver role strain related to isolation from friends AEB feelings of depression, disturbed sleep, states "I don't think I can do this much longer."
- excess fluuid volume related to excess fluid and sodium intake AEB 10 pound weight gain over 2 days, dyspnea, decreased hemoglobin and hematocrit
118
AEB
as evidenced by
119
potential at risk diagnosis
- differ from actual problem diagnoses in 2 ways
1. no defining characteristics (AEB)
2. no etiologic factor because nothing has yet happened
120
part 1 to potential or At Risk diagnoses
problem client is at risk for
121
part 2 to potential or At Risk diagnoses
- risk factors:
* why do you think client is at risk for the problem (can also be written related to)?
- examples:
* risk for violence related to history of violence, panicm hyperactivity, low impulse control
* risk for infection related to invasive procedure (surgery), immunosuppression, skin is not intact
122
client-centered goals
- priorities are set
* most clients have more than one problem
* use Maslow to determine highest priority
* keep the big picture in front of you
* sometimes it is not the "obvious" that needs attention first
123
expected outcomes of care
- goals/outcomes are determined and developed
- realistic
- measurable/observable
- cleint-centered vs. nurse-centered
124
client-centered
- goal reflects the client's expected behavior
- upon completion of the nursing action, this is what the client will be doing or will experience
- use to evaluate client progress
125
SMART
to write a goal
126
S=
specific
127
M=
measureable
128
A=
attainable
129
R=
realistic
130
T=
timed
131
nurse-centered
- describes the outcomes of nursing care
| - useful to evaluate overall quality of care and effectiveness of care
132
client-centered example
ex. Mrs. Smythe is suffering from depression and has cut off interaction with most of her friends and family.
ans. Client will participate in ongoing positive and relevant social activities.
133
goals for the client
- singular factors
* address only one outcome per goal
ex. client will maintain adequate oral intake (1500-2000 cc) and will describe measures to assure adequate intake continues.
- time-limited
* when should goal be accomplished?
ex. client will state 2 positive things about himself each day until discharge.
134
singular factors
address only one outcome per goal
135
time-limited
when should goal be accomplished?
136
short-term goals
- can be met quickly, generally less than a week
- focus on managing client's care while they are dependent
- focus on immediate needs
- focus on symptom relief
137
long-term goals
- achieved over longer periods of time, more than a week
- outcomes more appropriate for those with chronic illness
- meeting short-term goals leads to achievement of long-term goals
138
purposes of the nursing care plan
- written guideline for lient care
- coordinate nursing care: 24/7/365
- decreases the risk of incomplete, incorrect, inaccurate care
- helps organize information for charting and change of shift report
- provides outcome criteria on which to assess quality of care
- for students:
* teaches nursing process and critical thinking
139
dimensions of caring practice
- nursing interventions are nursing actions performed to prevent harm to client, prevent complications, provide comfort or to improve the mental, emotional, physical or social functions of the client
- actions to promote, maintain and restore health
- reflect caring through thoughtful and holistic care
140
nursing interventions: characteristics of the nursing diagnosis
- interventions should alter the etiological (related to) factor associated with the diagnostic label
- when an etiological factor cannot change, direct interventions toward treating the signs and symptoms
* NANDA-I defining characteristics
- for potential or high-risk diagnoses, direct interventions at altering or eliminating risk factors for the nursing diagnoses
141
nursing interventions: expected outcomes
- specify expected outcomes before choosing interventions
- identify for each patient the outcomes that can be reasonably expected and attained as the result of nursing care
- use the Nursing Outcomes Classification to specify outcomes
142
nursing interventions: evidence base
- know the research base for an intervention
- research will indicate the effectiveness of using an intervention with certain types of patients
- when research in not available, use scientific principles (ex. safety) or consult experts
143
nursing interventions: feasibility of the intervention
- a specific intervention has the potential for interacting with other interventions
- consider cost:
* is the intervention clinically effective and cost efficient?
- consider time:
* are time and personnel resources available?
144
nursing interventions: acceptability to the patient
- an intervention must be acceptable to the patient and family and match a patient's goals, health care values, and culture
- promote informed choice: help patient know how he or she is expected to participate
145
nursing interventions: capability
- be prepared to carry out the intervention
- be competent in knowing the scientific rationale for the intervention, possessing necessary psychomotor and interpersonal skills and being able to function in the particular setting
146
client advocacy
- nursing intervention
- nurse will objectively provide the client with the information they need to make decisions, (specify) and support the client in whatever decision they make
147
implementation
- nursing process
- category of nursing behaviors in which the actions necessary for achieving the goals of nursing care are initiated and completed
- is not completed until documentation is done
148
reassess the client
to assure that the plan is still appropriate
149
review and revise the Care Plan
- taking into account any changes
| - modify if needed
150
organize resources and care delivery
- have all equipment and supplies on hand
- if you need extra help, have them ready when you approach the client
- make sure environment is safe and private, well lit
- assist client to be as comfortable as possible
- inform them of what you are going to do
151
anticipate and prevent complications
- plan to stay with patient if they may be unsafe during care
- be aware of possible complications
- be alert to catch problems quickly
152
implement nursing interventions
- performing, assisting or directing ADLs
- teaching or counseling
- providing direct care
- delegating, supervising and evaluating the work of other staff
- recording and exchanging information
* at shift change
153
cognitive
- knowledge based skills
- knowing rationale for actions
- understanding of normal and abnormal responses
- recognizing client needs
- planning in accordance with client's developmental level
154
interpersonal
- ability to develop a trusting relationship with clients
- ability to communicate clearly
* open-ended questions
- sensitivity to client's emotional needs
- proper use of interpersonal skills
155
psychomotor
- integration of cognitive and motor activities
| - ability to do physical care competently
156
independent interventions
- nurse initiated
- autonomous action based on scientific rationale that is executed to benifit the client in a predicted way related to nursing diagnosis and client centered goals
- actions nurses are licensed to do without supervision or direction from others
- does not require an order from another discipline
157
dependent interventions
- physician initiated
- based on the physician's medical diagnosis, require an order that is carried out by the nurse
- are not actiond that the nurse can take based upon their own knowledge, education and licensure
- still require critical thinking to assess safety, appropriateness
158
interdependent interventions
- collaborative interventions
- therapies that require the knowledge. skills expertise of multiple health care professionals
- includes consultation with others, such as dieticians
159
evaluation
- nursing process
| - determining whether the patient has achieved the outcomes of the plan of care
160
process of evaluation
1. Examine the goal statement to identify the exact desired client behavior or response
2. Assess the client for the presence of that behavior or response
3. Compare established outcome criteria with behavior or response observed
161
degree of agreement
- step 4
- Met (completely)
- Partially met
* Has only part of outcome been achieved?
* Is the behavior present, but not consistently?
- Not met
162
met or only partially met
- step 5
- what prevented the outcome from being achieved?
- did the client not accept the plan?
- were there new problems that interfered?
- were the goals unrealistic?
163
recording findings
-step 6
exs.
-goal met, client ambulating length of hall once each shift
-goal partially met, client ambulating one half length of hall each shift
-goal not met, client refuses to bear weight on hip, ambulation only from chair to bed
164
reassessment
if goal has not been not been reached
165
steps of reassessment
1. assess current health status to determine if problem was correctly identified
2. delete inappropriate diagnoses, add new if needed
3. adjust outcomes to make more realistic or measurable
4. add, change or delete outcomes or change time frames
166
examine each intervention
- 5
- are the specific?
- were they realistic and appropriate?
- were interventions implemented consistently?
- are they appropriately individualized?
- were there environmental problems?
- change, add or delete interventions based on answers to those 5 questions
- set new target date for evaluation
167
documentation
anything written or printed that is a record or proof of activities
168
reports
accurate, organized accounting of care given by one provider to assist another with information needed to provide continuity of care
169
primary purpose of documentation
- provide an accurate accounting of care in the order it happened
- demonstrates continuity
170
quality of care the client receives
depends not only on the skill of the providers, but on the of information between providers
171
if you don't document...
it never happened
172
purpose of a health care record
- communication
- leagal documentation
- fincancial billing
- education
- nursing process
- research
- auditing and monitoring
173
parts of the client record
- admission sheet
* client ID and demographics
- informed consent for general treatment and any specific invasive procedures
- types of assessments
* health history
* physical exam
* diagnostic studies
* SW
* OT
- diagnoses
* medical
* nursing
- plan(s) of care
- therapeutic orders
* physician
* nursing
- progress notes
* all disciplines
- medication administration record (MAR)
- labd, advanced directives, DNR
- discharge plan and summary
174
admission sheet
- client ID
| - demographics
175
informed consent
for general treatment and specific invasive procedures
176
types of assessments
- health history
- physical exam
- diagnostic
- SW
- OT
177
therapeutic orders
- physician
| - nursing
178
progress notes
all disciplines
179
other parts of the client record
- medication administration record (MAR)
- labs, advanced directives, DNR
- discharge plan and summary
180
types of documentation
- problem oriented
- SOAP
- SOAPIE
- narrative
- focus charting
- PIE
181
problem oriented
- data are arranged according to the client's problems
- components:
* database
* problem list: chronological
* care plan: by discipline
182
problem list
chronological
183
care plan
by discipline
184
progress notes
- narrative:
* traditional
* use of story-like format to document client information
ex. 9/29/03 1310. Patient requesting medication for leg pain. Reports “6” on scale of 1-10. VS: T-100.4 F, P 110, R 32, BP 150/90. Patient received Codeine 60 mg po for pain. Pillow placed below leg, pt states “I feel much more comfortable now.” “2” on pain scale. Call bell within reach. A. Kramer RN -------------------------------
* needs to say when patient was reassesed and time
* needs second set of vitals
185
narrative
traditional, use of story-like format to document client information
186
SOAP
```
-headed by problem numer and title; originates from medical model
S=subjective data
O=objective data
A=assessment
P=plan
```
187
S=
subjective data
188
O=
objective data
189
A=
assessment
190
P=
plan
191
SOAP example
9/29/03 1310. ND 1: Pain--------------------
S. Reports “6” on 1-10 pain scale----------
O. VS, T-100.4 F, P 110, R 32, BP 150/90.
A. Pain------------------------------------------
P. Administer PRN Codeine 60 mg po per order. Reposition for maximum comfort.
A. Kramer RN -------------------------
192
SOAPIE
```
S=subjective data
O=objective data
A=assessment
P=plan
I=intervention
E=evaluation
```
193
I=
intervention
194
E=
evaluation
195
SOAPIE example
9/29/03 1310. ND 1: Pain--------------------
S. Reports “6” on 1-10 pain scale----------
O. VS, T-100.4 F, P 110, R 32, BP 150/90.
A. Pain------------------------------------------
P. Administer PRN Codeine 60 mg po per order. Reposition for maximum comfort.
I. PRN Codeine administered. Pillow placed under legs. Call bell within reach.
E. Patient states “I feel much more comfortable”. “2” on pain scale.
A. Kramer RN --------------------------
*needs a second set of vitals
196
PIE
-originates from nursing process
-based on daily assessments charted elsewhere
P=problem or nursing diagnosis
I=intervention, action taken
E=evaluation of outcome of Intervention
197
P=
problem or nursing diagnosis
198
I=
intervention, action taken
199
E=
evaluation of outcome of Intervention
200
PIE example
9/29/03 1310.---------------------------------
P. Pain related to tissue trauma-----------
I. Administered PRN codeine 60 mg per order. Repositioned in bed. Call bell within reach.--------------------------------
E. Patient states “I feel much more comfortable now.” Pain reduced from 6 to 2 on 10 point scale. A. Kramer RN -------
201
charting by exception
- notation made only when care deviates from standardized plan of care
- assumes everything not noted is completed as stated
- simple check-off or intialing suffices
- any notation is an easy way to see if the client is experiencing anything unusual
202
source records
all data grouped by discipline
203
focus charting
-focus in on current client situation
-does not label client concerns as "problems"
-DAR method used with each entry
D=data
A=actions
R=client response
204
D=
data
205
A=
actions
206
R=
client response
207
DAR example
9/29/03 1310 Focus: Pain-----------------
D. Patient requesting medication for leg pain. Reports 6 on scale of 1-10. VS: T 100.4 F, P 110, R 32, BP 150/90.
A. Given prn Codeine 60 mg po. Pillow placed below leg.-------------------------
R. States “I feel much more comfortable”. Pain 2 on scale 1-10. A. Kramer RN --------
208
critical pathways
- one or two paged multidisciplinary standardized plans of care
- charting is done on the form, by all disciplines
- resembles charting by excretion in that only variances (abnormal) are noted, positive or negative
209
reports
- shift reports
* basic information
1. name, age, admission date
2. room number
3. physician
4. medical diagnoses
5. surgical procedures
6. nursing diagnoses
- give exact information
* NOT "Mr. Jones got Demerol for pain." Rather: "Mr. Jones received Demerol 100mg IM at 2130 for pain in his left leg."
* include vital signs and reassessment
- do not include unremarkable measurements
- report emotional responses that need attention or are of particular note
- keep it quick and efficient
- keep in objective
- may be given live or via audiotape
210
shift reports
- basic information:
1. name, age, admission date
2. room number
3. physician
4. medical diagnoses
5. surgical procedures
6. nursing diagnoses
211
charting tips
-use black ink and be legible. print if handwriting is not clear
-write notes as soon as possible after giving care: improves accuracy
-be precise. exactly how, when and where events occurred
-sign all entries, first initial, last name plus credential, or as agency requires
ex. A. Kramer RN
-no blank spaces. draw a line
-be concise, yet descriptive
-to correct an error draw a single line through entry, write 'error' above and initial
-be specfic, don't use vague terms
exs.
-ate poorly---ate1/2 meal and drank 80ml fluid
-intoxicated---BAL 0.25, slurring of words, unable to walk without assistance
-uncooperative---refused to brush teeth or wash own face
-cofused---did not recognize wife and children
212
telephone orders and reports
-if significant events or changes are reported over the phone, document in permannet record
ex.
-R. Kiley, MD notified at 1530 that pt's potassium level is 2.7 mEq/L.------------
A. Kramer RN-----------------------------------
-receipt of physician orders over the telephone:
*must be received by an RN (or per agency policy)
*state your name, patient's name, room number and diagnosis when speaking to physician
*always repeat order back to assure accuracy
-document immediately in following format:
T.O. 9/29/03, 1500. Diphenhydramine 50mg IM q 1 hour PRN for dystonic response. R. Kildare MD/ A. Kramer RN, read back and confirmed
-some agencies require 2 RNs to verify
-physician must sign within agency time period
-never use for physician convenience or for routine orders
-verbal orders, when physician is present are not to be accepted except in dire circumstances
213
transfer reports
- when client is moved from unit to anither same shift report, plus:
* medical progress summary
* current status
* any critical assessments or treatments that are due soon
* any special equipment needs
- time to answer questions
214
SBAR
Situation
Background
Assessment
Recommendation
215
SHARED
```
Situation
History
Assessment
Recommendation
Evaluation
Documentation
```
216
flow sheets
- allow for documentation of routine observations or specific measurements made repeatedly
- negates need for other charting
- only significantchanges charted elsewhere
217
graphic sheets
allow for graphing of things like vital signs, weight
218
kardex
- nursing information needed for daily care and quick access
| - kept separetly from chart
219
incident reports
-any incident that is not consistent with the routine of the unit, client, visitors
exs:
-falls
-needle sticks
-visitor becoming ill
-medications errors
-chemical spills
-not part of permanent client record
-primarily a tool to assist in quality improvement. needs for changes in practice, policy, education, are tracked
-person who witnesses or finds problem is one who writes report
-if incident involves client, seperate note is placed in char. chart only what is observed and reported, no assumptions
220
well written incident report
Responded to call bell. Client observed on floor near bathroom. He was attempting to stand up. Assisted to chair. VS WNL, PERRLA. No cognitive problems noted. Pt states “I feel a little foolish. I didn’t wait for you to come. I didn’t put my slippers on and my socks were slippery on the tile.” Physician notified. Continue to monitor.
221
incident reports should include
- Date and time of incident
- Condition of patient when found
- Witness information
- Assessment for injury
- Actions taken
- Any follow up notations
222
medication incident reports
- An accurate and concise description of the error
- Relevant information-without making excuses
- Any adverse reaction by client
- How you will prevent the error from recurring
* practice policies and procedures
223
mecation error incident report example
Received Codeine 60 mg PO at 1530. Order was for 30 mg PO at 1530. Dr Jones notified. Mr. Smith became drowsy within an hour, VS WNL. He was responsive to stimulation, states “I feel like I could sleep all night, just like when I usually get the 60 mg dose.” Physician notified, VS monitored q hour until HS. A. Kramer RN---------
