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Observation, Reporting, and Documentation Unit 8.

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Presentation on theme: "Observation, Reporting, and Documentation Unit 8."— Presentation transcript:

1 Observation, Reporting, and Documentation Unit 8

2 Nursing Process Steps of Nursing Process:Steps of Nursing Process: AssessmentAssessment PlanningPlanning ImplementationImplementation EvaluationEvaluation

3 Nursing Process Assessment: learning about the patientAssessment: learning about the patient Nursing assistant actions include:Nursing assistant actions include: Observing carefully during admission processObserving carefully during admission process Listening carefully to what the patient and family sayListening carefully to what the patient and family say Measuring vital signsMeasuring vital signs Reporting findings to the nurseReporting findings to the nurse

4 Nursing Process Assessment: learning about the patientAssessment: learning about the patient Nursing assistant actions include:Nursing assistant actions include: Reporting changes in the patient’s condition, response, and behavior promptlyReporting changes in the patient’s condition, response, and behavior promptly If permitted, charting or documentingIf permitted, charting or documenting Charting: vital signs, intake/output (objective)Charting: vital signs, intake/output (objective) Documenting: observations (subjective/objective)Documenting: observations (subjective/objective)

5 Nursing Process Planning: preparing the nursing planPlanning: preparing the nursing plan Nursing assistant actions include:Nursing assistant actions include: Being informed of, and following the nursing care planBeing informed of, and following the nursing care plan Participating in the planning conferenceParticipating in the planning conference Contributing information and observations that will help the team develop a planContributing information and observations that will help the team develop a plan

6 Nursing Process Implementation: seeing that the care plan is followedImplementation: seeing that the care plan is followed Nursing assistant actions include:Nursing assistant actions include: Carrying out assignments correctlyCarrying out assignments correctly Being willing to cooperate and help other team membersBeing willing to cooperate and help other team members

7 Nursing Process Evaluation: determine how well care plan goals have been metEvaluation: determine how well care plan goals have been met Nursing assistant actions include:Nursing assistant actions include: Reporting your observationsReporting your observations Inform the nurse if an approach cannot be implementedInform the nurse if an approach cannot be implemented Informing the nurse if the patient has problems with a listed approachInforming the nurse if the patient has problems with a listed approach

8 Making Observations Observing is an important part of the nursing assistant's job, which includes:Observing is an important part of the nursing assistant's job, which includes: Using all of your senses when making observationsUsing all of your senses when making observations Noting anything unusual or extraordinaryNoting anything unusual or extraordinary Reporting your observations to your team leader in an accurate, timely mannerReporting your observations to your team leader in an accurate, timely manner

9 Making Observations Observations of normal values:Observations of normal values: The nursing assistant must have basic knowledge of the range of normal observationsThe nursing assistant must have basic knowledge of the range of normal observations Anything outside the range of normal should be reported to the nurseAnything outside the range of normal should be reported to the nurse

10 Making Observations Observations of specific body systems:Observations of specific body systems: Integumentary system:Integumentary system: Color, temperature, flexibility (turgor), dryness, moisture, redness, open areas, bruises, swelling, scars, rashesColor, temperature, flexibility (turgor), dryness, moisture, redness, open areas, bruises, swelling, scars, rashes Musculoskeletal system:Musculoskeletal system: Deformities, ability to walk, sit, or move, pain, posture, or abnormal movementsDeformities, ability to walk, sit, or move, pain, posture, or abnormal movements Circulatory system:Circulatory system: Skin color, heart rate, pulse, blood pressure, nails, lower extremitiesSkin color, heart rate, pulse, blood pressure, nails, lower extremities

11 Making Observations Observations of specific body systems:Observations of specific body systems: Respiratory system:Respiratory system: Difficulty breathing, blueness of skin, shortness of breath, rate of respirations, noisy respiration, coughDifficulty breathing, blueness of skin, shortness of breath, rate of respirations, noisy respiration, cough Nervous system:Nervous system: Level of consciousness, response to questions, paralysis, orientation to time & place, condition of eyes & earsLevel of consciousness, response to questions, paralysis, orientation to time & place, condition of eyes & ears

12 Making Observations Observations of specific body systems:Observations of specific body systems: Urinary system:Urinary system: Frequency, amount and character of urine, inability to hold urine, drainage, color of urine, blood in urine, pain during urinationFrequency, amount and character of urine, inability to hold urine, drainage, color of urine, blood in urine, pain during urination Digestive system:Digestive system: Appetite, tolerance to certain foods, diarrhea, constipation, gas, difficulty chewing or swallowing, unusual color or consistency of stool, nausea, vomitingAppetite, tolerance to certain foods, diarrhea, constipation, gas, difficulty chewing or swallowing, unusual color or consistency of stool, nausea, vomiting

13 Making Observations Observations of specific body systems:Observations of specific body systems: Endocrine system:Endocrine system: Signs and symptoms of hypo/hyperglycemiaSigns and symptoms of hypo/hyperglycemia Reproductive system:Reproductive system: Abnormalities of the breasts, menstrual cycle, and vaginal discharge, lumps in testes, abnormal drainage from the penisAbnormalities of the breasts, menstrual cycle, and vaginal discharge, lumps in testes, abnormal drainage from the penis Other observations:Other observations: Pain, behavior, ability to functionPain, behavior, ability to function

14 Making Observations Observations of pain:Observations of pain: Pain is never normalPain is never normal Body language and facial expressions may provide clues to the presence of pain, particularly in children and cognitively impaired adultsBody language and facial expressions may provide clues to the presence of pain, particularly in children and cognitively impaired adults The patient’s self-report of pain is always the most accurate; avoid making assumptions about pain (subjective)The patient’s self-report of pain is always the most accurate; avoid making assumptions about pain (subjective) Pain scales are used to help patients communicate level/intensity of painPain scales are used to help patients communicate level/intensity of pain

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18 Reporting A “report” is given by staff going off duty to the oncoming shiftA “report” is given by staff going off duty to the oncoming shift Oral Reporting:Oral Reporting: Most accurate because it is “up to the minute”Most accurate because it is “up to the minute” Face to faceFace to face Allows for questionsAllows for questions Allows for review of medical records, lab results, etc.Allows for review of medical records, lab results, etc.

19 Reporting A “report” is given by staff going off duty to the oncoming shiftA “report” is given by staff going off duty to the oncoming shift Written report:Written report: Less accurateLess accurate Writing can be illegibleWriting can be illegible Details can be omitted for sake of brevityDetails can be omitted for sake of brevity Events that occur after report is written may not be updated on report for oncoming shiftEvents that occur after report is written may not be updated on report for oncoming shift Can be “misplaced”Can be “misplaced” Can be HIPPA violation if not securedCan be HIPPA violation if not secured

20 Documentation General guidelines for charting:General guidelines for charting: PRINT entries as neatly as possible, unless cursive entries are allowed – must also be neat and legiblePRINT entries as neatly as possible, unless cursive entries are allowed – must also be neat and legible Use BLACK ink for all entriesUse BLACK ink for all entries Use short, concise, factual phrases – no opinionsUse short, concise, factual phrases – no opinions Always chart after the event – NEVER beforeAlways chart after the event – NEVER before Always enter time of event in entryAlways enter time of event in entry

21 Documentation General guidelines for charting:General guidelines for charting: Leave no blank spaces when documentingLeave no blank spaces when documenting Sign EACH entry with first initial, last name and your titleSign EACH entry with first initial, last name and your title NEVER, ever (next slide please…..)NEVER, ever (next slide please…..)

22 Documentation General guidelines for charting:General guidelines for charting: NEVERNEVER

23 Documentation General guidelines for charting:General guidelines for charting: Leave no blank spaces when documentingLeave no blank spaces when documenting Sign EACH entry with first initial, last name and your titleSign EACH entry with first initial, last name and your title NEVER, ever erase, use “white-out,” or repeatedly cross through an error.NEVER, ever erase, use “white-out,” or repeatedly cross through an error. Draw single line through error, print word “error,” and initial. Single lineDraw single line through error, print word “error,” and initial. Single line Use medical terms appropriately and spell them correctlyUse medical terms appropriately and spell them correctly CER error

24 Documentation General guidelines for charting:General guidelines for charting: Use international (military) time when you document, or follow your facility’s policyUse international (military) time when you document, or follow your facility’s policy 1:00 PM = 1300 Hours1:00 PM = 1300 Hours 12:00 AM (midnight) = 0000 Hours12:00 AM (midnight) = 0000 Hours


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