Quiz 3 Nursing process, documentation, VS

What are the purposes of documentation?

Documented communication

Permanent record for accountability

Legal record of care

Teaching

Research and data collection

S in SBARR

Situation - situation of patient

B in SBARR

Background - medical history of patient

A in SBARR

Assessment - nursing assessment

First R in SBARR

Recommendation - patient teaching

Second R in SBARR

Read back - reading an order back for confirmation

Chart

a legal record that is used to meet the many demands of the health accreditation, medical insurance, and legal systems

Charting

process of adding information to the chart, recording or documenting the interventions carried out to meet the patient’s needs

Auditors

To improve quality of care to the patient, to see whether all ordered care were carried out and treatments were noted

Peer Review

Appraisal by professional coworkers of equal status

Quality assurance, assessment, and improvement

QAPI; evaluates services provided and the results achieved compared with accepted standards

Diagnosis-related groups (DRGs)

System classifying pt by age, diagnosis, and surgical procedure; basis for reimbursement rates for Medicare and Medicaid

Who is the legal owner of a client’s medical record?

The institution

How can a patient access their records?

By following established rules of facility

Traditional recording method

Narrative; written in abbreviated story form; includes: PT need or problem data, whether someone was contacted, care and treatments provided

Problem-oriented medical record (POMR)

is organized according to the scientific problem-solving system or method

SOAPIER

S-subjective, O-objective, A-assessment, P-plan, I-intervention, E-evaluation, R-revision

Focus charting

a modified list of patient problems statements is used as an index for nursing documentation

DARE focus charting

Data, Action, Response and evaluation, education and patient teaching

Charting by exception (CBE)

only additional treatments given or withheld, changes in patient condition, and new concerns are charted

Charting Dos

correct patient name, identification number, date of birth, date, and time; be objective in charting; chart as soon and as often; Fill all spaces, grammar and punctuation; use direct quotes

Charting Dont’s

avoid generalized empty phrases; do not erase, apply correction fluid, or scratch out errors made while recording; do not speculate, guess or assume; no opinions; never use charting to accuse someone

Breach of confidentiality

do not share password used to log into computer; do not leave computer terminal unattended without logging off; be sure stored records have backup files; don’t leave information about a patient displayed on a monitor

Who can access client’s medical records?

lawyers, with pts written consent

Nursing process

method by which nurses plan and provide care for patients

ADOPIE

Assessment, Diagnosis, Outcomes identification, Planning, Implementation, Evaluation

Assessment

RN is responsible for initial assessment; LVN assists with ongoing assessments

ADOPIE assessment; what do you do

Observe and report significant cues to the nurse in charge

ADOPIE diagnosis what do you do

Assist with the determination of accurate patient problem statements

ADOPIE outcome planning what do you do

Assist with setting priorities, suggest interventions

ADOPIE implementation what do you do

Carry out health care provider and planned nursing interventions

ADOPIE evaluation what do you do

Assist with reevaluation of the patient’s health state after nursing interventions

ADOPIE

Rn is responsible

IE

LVN implement the proposed plan and evaluates plan

Constant principle of nursing

If it was not charted, it was not done

what helps the continuity of care?

it is important to have written guidelines to promote the continuity of patient care

Subjective data

verbal statements provided by the patient

Objective data

observable and measurable signs

Primary source of data

Patient during assessment

Secondary source of data

Family members, significant other, medical records, diagnostic procedures

DNR

Do not resuscitate

Who is responsible for analyzing and interpreting data?

RN is responsible

Who can access client’s medical records?

Physician, Physician’s Assistant, Client

What PPE to wear with droplet precautions

surgical mask

What PPE to wear with airborne precautions

N95 mask

What PPE to wear with contact precautions

gown and gloves

How do you take an adult’s tympanic temperature?

Pull the pinna up and back and insert into ear

How do you take a child’s tympanic temperature?

Pull pinna straight back

Range for pulses

100-160 BPM for infants, 80-130 toddler, 60-100 adults

Bradycardia and tachycardia

<60 bradycardia, >120 tacycardia

Factors that could increase HR and/or Temp

Age, exercise, hormonal influences, stress, environment, ingestion of foods (oral temps hot or cold), smoking; hemorrhage, medications, metabolism, postural changes

How to take an apical pulse

5th intercostal midclavicular line for adults, 4th intercostal for children under 7

Factors that cause dyspnea

positions of discomfort, cyanotic nail beds, lips, or mucous membranes

Stage I hypertension

130-139/80-89

Stage II hypertension

140 or higher/ 90 or higher

Hypertensive crisis (Emergency care needed)

>180/ >120

How to take BP

cuff approx 40% of circumference, 30 mmHg above radial artery obliteration, deflate cuff at rate of 2 mmHg/s