Observation and Reporting

What are the five steps of the nursing process?

Assessment, Problem identification and nursing diagnosis, Planning, Implementation, Evaluation.

What is the role of the Nursing Assistant in the nursing process?

Responsible for reporting observations and data to the nurse.

What should you describe when reporting pain?

Details of the patient's pain experience, including problems, refusals, and potential alternative approaches.

What is a Subjective symptom?

A statement or complaint made by the patient regarding their feelings or experiences.

What is an Objective symptom?

A symptom that is factual, measurable, and observable.

How should signs and symptoms be reported?

Report facts only, avoiding any judgments or labels.

Why is it important for nursing assistants to know normal observations?

To inform the nurse and physician if a patient's condition is improving.

What method helps when making observations?

Giving an oral report to relay information effectively.

What details should you note when making observations?

Patient's appearance, behavior, and any changes in their condition.

What is the medical record?

A complete file of a patient's health history and care maintained by healthcare providers.

How do you use international (military) time?

Hours go from 00 to 23, with no AM or PM; add 12 for PM times.

What are some non-verbal signs of pain?

Facial expressions, body tension, moaning, or restlessness.

Should visual observations contribute to your report of a patient's pain?

No, the patient's statement about their pain takes priority.

What is the pain assessment (rating) scale used for?

To measure the level of pain a patient is experiencing on a scale from 0 to 10.

What does HIPAA do?

Protects patient privacy and limits access to authorized healthcare professionals.

Why is it necessary to link handheld computers to a full-size computer?

For data transfer, storage, and analysis.

What should you do with patient documents that are no longer needed?

Securely dispose of them, typically by shredding.

What does SBAR stand for?

Situation, Background, Assessment, Recommendation.

Who collects a Minimum Data Set (MDS)?

Nurses or healthcare professionals in long-term care facilities.

What are rules of documentation?

Accuracy, clarity, timeliness, and using approved abbreviations.

What is the electronic version of a paper medical record called?

An Electronic Health Record (EHR).

What is POCT and where is it performed?

Point-of-Care Testing, performed at the patient's bedside or nearby.

What is the purpose of a nursing diagnosis?

To identify and describe a patient’s health issues to guide care and treatment.