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RN Skills Laboratory

RN Skills Laboratory. Documentation Week 3. Objectives. Admission & Discharge Nursing History Charting Care Planning Reporting. Admissions. Advanced Directives Clients Bill of Rights Assessment by RN Clearly identifiable by wrist band Consent by adult guardians or DPOAs. Discharges.

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RN Skills Laboratory

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  1. RN Skills Laboratory Documentation Week 3

  2. Objectives • Admission & Discharge • Nursing History • Charting • Care Planning • Reporting

  3. Admissions • Advanced Directives • Clients Bill of Rights • Assessment by RN • Clearly identifiable by wrist band • Consent by adult guardians or DPOAs

  4. Discharges • Discharge instructions are given • Follow-up information is given • Education and handouts

  5. Nursing History • Essential elements of clinical care • Empathic listening • Interviewing at all ages, moods, and backgrounds • Examination of different body systems • Clinical reasoning • Structure and purpose • Comprehensive vs Focused • Subjective vs objective

  6. Nursing History • Initial Information • Identifying Data • Reliability • Chief Compliant (HPI) • Medications • Allergies • Past History • Medical, Surgical, Ob/Gyn, Psych

  7. Nursing History • Family History • Personal and Social History • Substance use: smoking, alcohol, drugs • Occupation, Education • Interest, coping, Strengths, Fears • Marital status, Home situation • Exercise/diet, alternative health • Safety, spirituality

  8. Nursing History • Review of the systems (ROS) • General • Skin • HEENT • Breasts • Respiratory • Cardiovascular, Peripheralvascular • Gastrointestinal • Urinary • Genital • Musculoskeletal • Psychiatric, Neurological • Hematologic, Endocrine

  9. HPI • Essential elements to gathering data for present illness • Usually start 2 days before • Then day before • Then the current day

  10. HPI • PQRSTU • Provocative or Palliative • Quality or Quantity • Region or Radiation • Severity Scales • Timing • Understanding

  11. HPI • OLDCARTS • Onset • Location • Duration • Character • Aggravating/associated symptoms • Relieving factors • Temporal factors • Severity

  12. Charting Guidelines • Procedure done • Detailed description of the procedure • Equipment used • Characteristics of expected or unexpected findings • Patient/family response • Care plan addressed • Signature, designation (J. Kennett, SN)

  13. Care Planning • Approved WCU Care Plan Template • Demographic information • Vital Signs • Admission Diagnosis • Diagnostic Procedures/Surgeries (with dates) • Discharge Referrals

  14. Care Planning • Erickson’s Developmental Stage • Socioeconomic/Cultural Orientation • Psychosocial Considerations • History of Present Illness • Past medical/surgical history (with dates) • Labs

  15. Care Planning • Pathophysiology (Need a med/surg text book – no Tabers or Internet) • Collaborative Problems • Prescriber’s Orders with rationale • Medication list • Risk problem • Actual problem

  16. Change of Shift Report • There is little agreement on what makes a good report • Report is information and relationship exchange • Change of shift report is part of nursing culture that can improve patient care

  17. Change of Shift Report • Be supported and therapeutic when communicating information • Provide information, actions and outcomes • Shift reports demonstrate the value of nursing actions, reflects nurses’ motivation and patient satisfaction

  18. Change of Shift Report • Avoid negative criticism, praise for work well done • Not merely a mechanism of communication but activities prescribed by the physician and nursing activities • Do not give commentaries of staff or patient management

  19. Change of Shift Report • Strategies in giving a good report • Incorporate into the plan of care • Site activities that have been done, and those that have not been done • What are the discharge plans • Make sure your notes are documented in the clinical record

  20. Change of Shift Report Example of a change of shift report

  21. Change of Shift Report Example of a narrative shift report • In room 2203-2 is John Doe • 78 year old male • Patient of Dr. Jones • Admitted with FUO, currently being treated for sepsis • His problems areas are….

  22. Change of Shift Report • Alert/Oriented now • B/P - stable the last 12 hours -110/70 at 1600 • Fluids - receiving IV replacement and taking PO • Output is improving 1800ml yesterday 2600ml today - we need an UA C&S in the AM • Social Services is talking about placement because the family can not continue to care for him at home

  23. Change of Shift Report References Hays, M.M. (2003). The phenomenal shift report: A paradox. Journal for Nurses in Staff Development 19 (1), 25-33. Mosher, C. & Bontomasi, R. (1996). How to improve your shift report. American Journal of Nursing 96(8), 32-34.

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