1 / 11

Component 2: The Culture of Health Care

Component 2: The Culture of Health Care. Unit 6: Nursing Care Processes Lecture 3. Focus of this Lecture. Routine activities for the staff nurse Additional activities Documentation for the nurse Technical tools. Typical Routine for a Hospital Staff Nurse. Work hours – 8 to 12 hour shifts

Download Presentation

Component 2: The Culture of Health Care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Component 2: The Culture of Health Care Unit 6: Nursing Care Processes Lecture 3 This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

  2. Focus of this Lecture • Routine activities for the staff nurse • Additional activities • Documentation for the nurse • Technical tools Health IT Workforce Curriculum Version 2.0/Spring 2011

  3. Typical Routine for a Hospital Staff Nurse • Work hours – 8 to 12 hour shifts • 4 to 5 acutely ill patients • Prepare for patient care: review patient records: diagnosis, history, treatment and care orders, medications; review plan of care and take report from the previous nurse • Review patient care plan Health IT Workforce Curriculum Version 2.0/Spring 2011

  4. Routine (continued) • Assess patient ( complete assessment at first visit then a focused assessment at least 4 hours • Administer medications, check IVs, lab test • Follow through on plan of care and make changes as needed • Provide comfort measures, pain assessment and control • Activities of daily living, dressing changes, ambulation, nutritional provisions Health IT Workforce Curriculum Version 2.0/Spring 2011

  5. Other Routine Activities • Collaborate with other personnel: MD, Nurses, CNA, PT, RT, Radiology, Lab services, nutrition, Social Services, discharge planners • Education for patient and family • Manage IV’s – start or discontinue • Lab work- blood draws, specimen collection Health IT Workforce Curriculum Version 2.0/Spring 2011

  6. Non-patient Routine Activities • Attend an in-service on new equipment • Cover for other nurses as they take lunch • Mentor Nursing Students Health IT Workforce Curriculum Version 2.0/Spring 2011

  7. Documentation Documentation is a vital component of safe, ethical and effective nursing practice, regardless of the context of practice or whether the documentation is paper-based or electronic. All components of a patient record is a legal document; data placed there must be factual, accurate, complete, dated and signed. Health IT Workforce Curriculum Version 2.0/Spring 2011

  8. Purpose • Documentation refers to written or electronically generated information about a client, describing the care or services provided to that client (e.g., charting, recording, nurses’ notes, or progress notes). • Documentation is an accurate account of events that have occurred and when they occurred. Health IT Workforce Curriculum Version 2.0/Spring 2011

  9. Expectations • A nurse is expected to record and maintain documentation that is clear, timely, accurate, reflective of observations, permanent, legible and chronological. • Accurate, timely documentation reflects care provided; meets professional, legislative and agency standards; promotes enhanced nursing care; • Facilitates communication between nurses and other healthcare providers. Health IT Workforce Curriculum Version 2.0/Spring 2011

  10. What would a nurse chart? • Vital signs • Assessment findings • Plan of care • Treatments • Medications • Intake and output • Pain level • Education • Telephone orders • Interaction with patient family members • Patient complaints • Discussion with family members • Admission and discharge notes Health IT Workforce Curriculum Version 2.0/Spring 2011

  11. Technical Tools • Computerized documentation systems can improve uniformity, accuracy, and retrievability of data. • Verbal communication systems – Vocera, pagers • Lab equipment • Assessment equipment • IV pumps • Pyxis machine • Simulation mannequins Health IT Workforce Curriculum Version 2.0/Spring 2011

More Related