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Understand nurse aide observations, recording, and reporting.Understand nurse aide observations, recording, and reporting. Nursing Fundamentals 72431 2.02.

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Presentation on theme: "Understand nurse aide observations, recording, and reporting.Understand nurse aide observations, recording, and reporting. Nursing Fundamentals 72431 2.02."— Presentation transcript:

1 Understand nurse aide observations, recording, and reporting.Understand nurse aide observations, recording, and reporting. Nursing Fundamentals 72431 2.02 Unit A Nurse Aide Workplace Fundamentals Nurse Aide Workplace Fundamentals Essential Standard NA2.00 Apply communication and interpersonal skills and physical care that promote mental health and meet the social and special needs of Apply communication and interpersonal skills and physical care that promote mental health and meet the social and special needs of residents in long-term care. residents in long-term care. Indicator 2.02 Understand nurse aide observations, recording, and reporting. Understand nurse aide observations, recording, and reporting.

2 Nursing Fundamentals 72432 Examples using sight: Rash Skin color Bruising Methods of Observation 2.02

3 Nursing Fundamentals 72433 Examples using hearing: Wheezing Moans Words spoken by resident Methods of Observation (continued) 2.02

4 Nursing Fundamentals 72434 Methods of Observation (continued) Examples using touch: Lump Temperature of skin Change in pulse 2.02

5 Nursing Fundamentals 72435 Examples using smell: Odor of breath Odor of urine Odor of body Methods of Observation (continued) 2.02

6 Nursing Fundamentals 72436 Reporting Reports are made: – immediately – thoroughly – accurately Use notepad and pencil to write down information for reporting 2.02

7 Nursing Fundamentals 72437 Reporting (continued) Report only facts, not opinions –objective data - that observed using senses –subjective data - that told to nurse aide by the resident 2.02

8 Nursing Fundamentals 72438 Reporting (continued) Observe resident’s environment and report safety hazards 2.02

9 Nursing Fundamentals 72439 Reporting (continued) When reporting, consider: –care or treatment given –time of treatment –resident’s response to care 2.02

10 Nursing Fundamentals 724310 Reporting (continued) When reporting, consider: –observations helpful to other health care workers –information resident has given that would affect his or her treatment –anything unusual about resident 2.02

11 Nursing Fundamentals 724311 2.02 Communicating with other Staff Members

12 Nursing Fundamentals 724312 Forms of Communicating Body language Reporting or communicating orally Written communications 2.02

13 Nursing Fundamentals 724313 Written Communications: Resident Care Plans Resident care plans prepared by nurse One for each resident Kept at nurses’ station 2.02

14 Nursing Fundamentals 724314 Written Communications: Resident Care Plans (continued) Working record to provide consistent, well-planned care on a daily basis Changed and updated as needed by licensed nurse 2.02

15 Nursing Fundamentals 724315 Written Communications: Resident Care Plans (continued) Information included: –Resident’s level of independence in ADL –Treatments –Statement of problems 2.02

16 Nursing Fundamentals 724316 Written Communications: Resident Care Plans (continued) Information included (continued): –Short-term and long-term goals –Plan to attain goals –Date plan initiated and reevaluated 2.02

17 Nursing Fundamentals 724317 Written Communications: Resident Care Plans (continued) Nurse aides contribute by: –Helping to identify problems –Attending care conferences 2.02

18 Nursing Fundamentals 724318 Written Communications: Resident Care Plans (continued) Nurse aides contribute by (continued): –Directing questions about plan to supervisor –Reporting resident response to treatment and activities 2.02

19 Nursing Fundamentals 724319 Written Communications: Resident‘s Medical Record Includes information from all disciplines providing direct service to residents 2.02

20 Nursing Fundamentals 724320 Written Communications: Resident’s Medical Record (continued) A record of: –assessments, implementations, evaluations –management plans –progress notes Permanent legal record 2.02

21 Nursing Fundamentals 724321 Written Communications: Resident’s Medical Record (continued) Purpose –Organizes all information on care in one document –Accountability so care can be evaluated –Documentation so there is knowledge of what each discipline is doing 2.02

22 Nursing Fundamentals 724322 Written Communications: Resident’s Medical Record (continued) Confidential information available only to health care workers involved in care of resident 2.02

23 Nursing Fundamentals 724323 Guidelines For Charting If Allowed By Facility Make sure entries are accurate and easy to read Always use ink Print, unless script is accepted form Do not use the term “resident” 2.02

24 Nursing Fundamentals 724324 Guidelines For Charting If Allowed By Facility (continued) Use short, concise phrases Always chart after care is performed Make sure writing legible and neat 2.02

25 Nursing Fundamentals 724325 Guidelines For Charting If Allowed By Facility (continued) Use only abbreviations accepted by facility Make sure spelling, grammar and punctuation are correct Do not record judgments or interpretations 2.02

26 Nursing Fundamentals 724326 Guidelines For Charting If Allowed By Facility (continued) Record in a logical and chronological manner Be descriptive Make sure all forms added to the chart contain identifying information 2.02

27 Nursing Fundamentals 724327 Guidelines For Charting If Allowed By Facility (continued) Avoid using words that have more than one meaning Use resident’s exact words in quotation marks whenever possible Always indicate the time of care 2.02

28 Nursing Fundamentals 724328 Guidelines For Charting If Allowed By Facility (continued) Leave no lines blank Sign each entry with first initial, last name and title Correct errors using facility procedure 2.02

29 Nursing Fundamentals 724329 2.02 Medical Terminology

30 Nursing Fundamentals 724330 Medical Terminology Medicine has a language of its own –Historical development –Composed mainly of Greek and Latin word parts –Consistent and uniform 2.02

31 Nursing Fundamentals 724331 Medical Terminology (continued) Three components –Prefixes –Root words –Suffixes Medical dictionary –Used for reference –Spelling is important 2.02

32 Nursing Fundamentals 724332 2.02 Abbreviations

33 Nursing Fundamentals 724333 Abbreviations Help health care workers communicate quickly and effectively Are shortened forms of words Reduce time needed to chart important information 2.02

34 Nursing Fundamentals 724334 Abbreviations (continued) Conserve space on medical record Used primarily in written communication 2.02

35 Understand nurse aide observations, recording, and reporting. 35  END  2.02 2.02Nursing Fundamentals 7243


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