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Report
Is initated immediately when there is a change in the resident’s condition
Legal Document
Objective Data
Observations using the senses; Based on facts
Subjective Data
Information you are told that you cannot observe through your senses; based on feelings or opinions
1:00am
0100
8:00am
0800
12:00am
0000 & 2400
12:00pm
1200
Family Support
Emotional Support & encouragement
7:24pm
1924
7:24am
0724
Military Time
Add 12 if above 12pm
Dont add between the am’s
11:00am
1100
Maslow’s Hierarchy of needs
Physiological needs
Safety and security
Love and belonging
Self Esteem
Self Actualization
Family help with resident
Include famliy in meal time
encourage family to assisst with feading or dining
Self Actualization
Hard to get
Empowering, enviroment, spirtiual growth
Nursing Process
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Assault
Any threat (no touch) or attempt to injure another person
Battery
Unlawful Touching of another person without consent
Felony
A serious crime that carries a penalty of at least one year of imprisonent
Misuse of narcotics
using controlled drugs in a manner other than intended
Defamation
False statement made to a third person that causes a person shame or ridicule or ruins a persons reputation
2 types Slander & Libel
Tort
Wrongful acts, not involving a contract, that result in physical injury, property damages, or damages to a person’s reputation
Malpractice
Providing bad care resulting injury
Act of commission
Negligence
Failure to provide care that is normally expected
Act of omission
1:00am
0100
9:27pm
2127
HCPR
What is caused for immediate dismissal
Abuse
Not reporting abuse
Aiding and abetting
Hazard
Anything in the resident’s environment that may cause illness or injury
OBRA Long term care temp
71 degrees-81
Fall Prevention Program
Assessing residents for risk
Interventions to minimize risks
Intrinsic falls
Result from residen’ts inner being
medication
Extrinsic falls
Result from those things outside of the resident
BEFAST
Blance
Eyes
Face
Arms
Speech
Time
Seizure
Involuntary contractions of muscles
Note the time start and finish
dont leave resident
protect the head
loosen clothing
Prevent choking
keep resident up for 30 minutes
RACE
Remove resident
Activate alarm
Contain the fire
Extingush the fire
PASS
Pull the pin
Aim at the base of fire
Squeeze of the operating handle
Sweep from side to side
Correcting a documentation error
Draw one line through it, correct it, then initial/date it.
Plan of care
Contains resident needs, goals, and care instructions.
When is an incident report completed
After an unexpected accident or event.
Ethical behavior
Honesty, privacy, confidentiality, fairness, and respect
Non-traditional restraint
Furniture or devices used to prevent a resident from moving freely.
Restraint strap slack
Usually enough room for two fingers.
Restraints
informed consent is required
Skin can breakdown (decubitus ulcer & pressure ulcer the same thing)
Swelling (Edema)
Chemical restraints
drugs or drug doses used to control behavior or restrict movement
Physical restraints
manual method, physical or mechanical device
Check ___ for restraints
every 15mins
1-2 inches of slack
Recording Time
remove/release restraint
at least every 2 hours for at least 10 minutes