Documentation
Must be clear, accurate, concise and accessible. There should be a clear understanding and picture of the client. This also allows the interprofessional team to communication.
P.I.E
Problem
Intervention
Evaluation
Subjective
What the client is describing
Objective
What the health care provider sees, hears, touches, measure or smells
Assessment
Combines subjective & objective info to arrive at the nursing diagnosis
Plan
Details steps to treat clients and suggests the need for consultation, or additional testing to address the clients needs.
Source oriented
A traditional format for documenting within a medical record. It can be divided into sections like history, physical, progress notes, nurses notes, lab reports, and diagnostic testing.F
Focus Charting
focuses on health care problems and changes in condition, client events, and concerns
D.A.R
Data, Action, Response
Charting by exception
Documenting only unexpected or unusual findings
Problem oriented medical records
Developing a database (client’s history, findings, diagnostics, and laboratory results).
Identifying and numbering specific problems based on the client’s history. The date the problem is resolved is noted.
Formulating a plan of action for each problem.
Noting ongoing progress for each problem.
F.A.C.T
Factual, Accurate, Complete, and Timely
Error in documentation
Keep the OG document, draw an single line and write error with ur initials.Write the date & time. Do not obscure the original entry with a marker, pen, white out, etc..
Late charting entry
Identify the entry as "late entry", identify which even the late entry is for, make sure its signed & dated, no blank lines, and which event or previous note is referencing
Electronic Health Records(EHR)
Allows comprehensive records a person's health history & communication for all health care providers.
Electronic Documentation Guidelines
Dont use anyone else's login, use a strong password, log off completely when documentation is done, log off if ur leaving ur station, try to avoid info being seen by others. If an electronic signature is used, ensure your name is correct and professional credentials are noted.
The Institute for Safe Medication Practices (ISMP)
preventing errors that occur within health care facilities
Nursing Process
Help nurses make clinical judgment that are appropriate for clients
Assessment
assess the objective and subjective data that pertains to the client
Analysis
determine the clients problem
planning
create a plan to address the clients problems
implementation
taking action to provide care
evaluation
the effectiveness of interventions provided and document the clients response
Data collection for Lvn
collects subjective and objective data bout the client and report changes to the RN
planning for Lvn
create a plan to address client problems under the supervision of the RN
implementation for Lvn
collaborating with the RN to take action
Evaluation for Lvn
Evaluate the effectiveness of the interventions provided, within the LVN scope of practice, and under the supervision of the RN.
Steps
The steps usually go in order but at some point the process can go back and forth between the steps. Such as planning, implementation, and evaluation, to meet optimal results.
Critical thinking
Its the skill of learning to analyze and interpret data to solve a problem. This includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity.
Clinical reasoning
analyzing all the data and making a decision based on the analysis.
Clinical Judgment
The visible or observed outcome of critical thinking and decision making that considers nursing knowledge, client situations, and prioritization of client problems and concerns, while utilizing evidence-based practice.
Delegation
Nurses must remember that clinical reasoning and judgment cannot be delegated.
Intervention
being able to intervene on high risk problems
Priority setting
delivery of nursing care based on the importance or urgency of a clients needs
Maslow's hierarchy of needs
Levels of the pyramid- from the top is Self-actualization, Esteem, social belonging, safety needs, physiological needs
A.B.C.D.E
Airway, Breathing, Circulation, Disability, Exposure
C.U.R.E
Critical, urgent, routine, and extra
Critical
life-threatening situations
Urgent
Situations in which the client could suffer harm of discomfort if there is a delay in addressing the client's needs.
Routine
Routine tasks associated with client care.
Extras
Tasks that are not essential to client care but promote comfort.
Triage
Prioritizing what can be done quickly on a client
Levels of Triage
level 1 as the most urgent category with clients experiencing a life-threatening illness and level 5 as the least urgent category with clients being stable and suffering from nonemergency ailments.
Resource Allocation
the process of assigning a portion or amount of a service
Client care coordination
nurses must be aware of their role on the health care team and how to mange time and organize client care activites
Time management
nurse must know how to prioritize client care activities according to tome constaints
S.M.A.R.T
Specific, Measurable, Attainable, Realistic, Timely
S.B.A.R
Situation-Background-Assessment-Recommendation
S.O.A.P
Subjective, Objective, Assessment, and Plan
Measuring client acuity levels
helps ensure client assignments are consistent and fair.
Acuity tools may vary by facility, but basically clients are ranked from stable to high risk based on the tasks involved in their care.
I.D.E.A.L discharge planning
(I) Include the client and caregivers.
(D) Discuss the 5 key areas: medications, home life, warning signs, test results, follow-up.
(E) Educate the client: condition, discharge process, next steps.
(A) Assess effectiveness of education.(L) Listen to the client’s goals and preferences.
Delegation
one person assigning tasks to another
5 rights of delegation
Right task, Right circumstance, Right person, Right directions and communication, Right supervision and evaluation
Team nursing
Pairs two or more nurses together as a team to care for a group of clients. This helps with increased team work and sharing responsibilities
Non compliance
failure to act in accordance with a plan
Barriers to Interprofessional collaboration
Miscommunication, Distrust, Lack of respect among provider types, Different levels of perceived importance, Misunderstanding of each other’s roles
Interprofessional Education Collaborative (IPEC)
Values and ethics for interprofessional practice, Roles and responsibilities, Interprofessional communication, Teams and teamwork
The Chain of infection
A sequence of necessary pieces for an infection to occur, includes an infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.
Infectious agent
contains bacteria, fungi, virus, parasite, or prion.
Reservoir
the habitat of the infectious agent and is where it lives, grows, and reproduces itself or replicates.
Portal of entry
opening from the body, ( ears, nose, mouth) or can even be through skin
Portal of Exit
when the infectious agent can leave the reservoir.
Susceptible host
it's when the infectious agent to take hold and become a reservoir for infection
3 Modes of Transmission
Contact -microorganisms move from an infected person to another person.
Droplets-when airborne droplets from the respiratory tract of a client travel through the air and into the mucosa of a host
Airborne-when small particulates move into the airspace of another person.
Two types of Contact Transmission
Direct Contact, Indirect Contact
Direct contact
when microorganisms are directly moved from the infected person to another person without having a contaminated object or person between the two.
Indirect contact
when microorganisms are moved from the infected person to another person with a contaminated object or person between the two.
Nonspecific immunity
when neutrophils(white blood cell) and macrophages and their work as phagocytes(obsorbing bacteria).
Specific immunity
refers to the work of antibodies (also called immunoglobulins) and lymphocytes. Antibodies bind to infectious agents and call to the white blood cells and complement to destroy them.
The Inflammatory response
Inflammatory pathways are activated, Inflammatory markers are released, Inflammatory cells are recruited
Stages of infection
- Incubation: An infection enters host and begins to multiply.
- Prodromal: The client begins having symptoms.
- Acute illness: Manifestations of the specific infectious disease process are obvious and may become severe.
- Decline: Manifestations begin to wane as the degree of infectious disease decreases.
- Convalescence: The client returns to a normal or a “new normal” state of health.
Local infections
they are confined to one area of the body. Local infections can be treated with topical antibiotics and oral antibiotics.
Systemic infections
it start as local infections and then spread to the bloodstream to infect the entire body.
Hand hygiene
Cleaning the hands with handwashing, alcohol based hand sanitizer, using an antiseptic handwash or hand rub, and surgical hand antisepsis.
Medical asepsis
the elimination of and absence of disease-causing microorganisms.
Standard precautions
describing the infection prevention practices applied to all clients, whether or not they are known to have an infectious agent. Ex. ( masks, gloves, gowns, glasses, etc.)
4 major H.A.I.S
- Central Line-associated Bloodstream Infections (CLABSIs)
- Catheter-associated Urinary Tract Infections (CAUTIs)
- Surgical Site Infections (SSIs)
- Ventilator-assisted Pneumonias (VAPs)
P.P.E
Personal Protective Equipment, knowing what is needed to care for clients and how to don and doff approprately