NURSING AS A SCIENCE 6

• ADMISSION NURSING ASSESSMENT

   

  • also referred to as an initial database, nursing history, or nursing assessment, is completed when the client is admitted to the nursing unit
• NURSING CARE PLAN

   

  2 types:

  1. TRADITIONAL CARE PLAN – written for each client
  2. STANDARDIZED CARE PLAN – were developed to save documentation time.
• KARDEXES

   

  • is a widely used, concise method of organizing and recording data about a client, making information quickly accessible to all health professionals

   
• FLOW SHEETS

   

  • enables nurses to record nursing data quickly and concisely and provides an easy – to – read record of the client’s condition over time
• FLOW SHEETS

  • GRAPHIC RECORD – typically indicates body temperature, pulse, respiratory rate, blood pressure, weight
  •      INTAKE AND OUTPUT RECORD
  •      MEDICATION ADMINISTRATION RECORD
  •      SKIN ASSESSMENT RECORD
• PROGRESS NOTES

   

  • made by nurses provided information about the progress a client is making toward achieving desired outcomes
• LONG – TERM CARE DOCUMENTATION

   

  TWO TYPES OF CARE

   

  1. SKILLED – clients needing skilled care require more extensive nursing care and specialized nursing skills.
  2. INTERMEDIATE – is needed for clients who usually have chronic illness and may only need assistance with activities of daily living
• HOME CARE DOCUMENTATION

   

  2 records are required

  a)        Home health certification and plan of treatment form

  b)       A medical update and client information form
• REPORTING

   

  • To communicate specific information to a person or group of people
• CHANGE – OF – SHIFT REPORTS

   

  • “HAND OFF” COMMUNICATION – a process in which information about patient/client/resident care is communicated in consistent manner including an opportunity to ask and responds to questions
• SBARR - Allows for an easy and focused way to set expectations for what will be communicated and how member of the team, which is essential for developing teamwork and fostering a culture of patient safety
• S = SITUATION

  B = BACKGROUND

  A = ASSESSMENT

  R = RECOMMENDATION

  R = READ BACK
• TELEPHONE REPORTS

   

  • health professionals frequently report about a client by telephone
• TELEPHONE ORDERS

   

  • primary care providers often order a therapy for a client by telephone
• CARE PLAN CONFERENCE

   

  • is a meeting of a group of nurses to discuss possible solutions to certain problems of a client.
• NURSING ROUNDS

   

  • are the procedures in which 2 or more nurses visit selected clients