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How am I How are You Nursing Assessment

Objectives. State how your patient's assessment of you affects your assessmentsState how the language you use affects your assessmentsAssess within your scope of practiceState the importance of legibilityDocument accidents appropriately. Objectives. Review penalties for violations of nursing lawState some rules/risks of telephone triageState the risks of poor follow up resulting from poor assessmentsReview some resources for triage for your specialty.

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How am I How are You Nursing Assessment

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    1. How am I? How are You? Nursing Assessment Mary Kayse, RN, MSN, PNP-BC Eau Claire Cooperative Health Centers, Inc.

    3. Objectives Review penalties for violations of nursing law State some rules/risks of telephone triage State the risks of poor follow up resulting from poor assessments Review some resources for triage for your specialty

    4. Patient’s assessment How you are dressed? How you speak? Do you make eye contact? Are you talking about others in front of them? Are you texting/talking on phone while you are doing their assessment?

    6. Professional Dress Hairstyle Perfume Tattoos Jewelry Fingernails Attire Nametag – 1X3 inches with title

    11. Your words Clarify—What do you mean by that? Reflect back—So you are saying… Clarify—Show me…. He said/She said—use quotes

    12. SC code of laws Title 40 Chapter 33 #61 Scope of Practice SC Code of Laws “Unlicensed assistive personnel” or “UAP” are persons not currently licensed by the board as nurses who perform ROUTINE nursing tasks that DO NOT require a specialized knowledge base or the judgment and skill of a licensed nurse….tasks must be performed under the supervision of an APRN,RN, or selected LPN.

    14. Assessments Vital signs Medical History Family History Social History Health Habits Hobbies and special info With whom can you share health information?

    15. Violations SC Code of Laws Section 40-33-10 “…the board may cancel, fine, suspend, revoke, issue a public reprimand…”

    16. SC Code of Laws Section 40-33-10 Violations Disseminated a patient’s health or personal information acquired during the course of practice to persons not entitled by law or hospital or agency policy to disclosure of this information Failed to make or keep accurate, intelligible entries in records as required by law, policy or standards

    17. SC Code of Laws SEction 40-33-110 Violations Practiced outside the scope of the license by assuming duties and responsibilities without adequate education as determined by the board Assigned unqualified persons to perform nursing care functions, tasks, or responsibilities or failed to actively supervise persons ….

    18. Legibility Print if you must Use your spell check or drug handbook Errors are one line out, date, and full name Late entries must be labeled as such Leading and trailing decimals Only approved abbreviations

    19. Accuracy Temp—oral/rectal/axillary/subjective Wt/Ht—w/shoes, purse, which scale Blood sugar—fasting, last meal Plotting Wt/Ht Labs, done appropriately, charted accurately Meds—white pill, letters BPS, scored, says it is for her BP

    21. Know when to get help Respiratory distress Change in level of consciousness Chest pain Psychotic behavior Violent behavior Needs outside your scope of practice

    22. Telephone triage

    23. Telephone triage RN’s are considered the best choice (for telephone triage) not only because they are autonomous professionals, but they are also “the lowest paid person who can safely do the job” (Schmidtt, 1980)

    24. Telephone Triage Smile when you talk No multi-tasking Use your good manners Take notes Stick to the triage protocols Return calls promptly – one hour turn around should be the goal

    26. Don’t chart this!!! Belligerent, trashy, smelly Instead, patient yelled loudly that “xxxxxxxxxxxxxxxx”, patient repeatedly……. See incident report Instead put what happened, “Patient found on floor, care given, injuries found, notified XYZ”

    27. Follow Up, Follow Up, Follow Up Working phone number (the REAL one) Address When are you home? Where else might you be? Who else can I talk to? Any home impediments—stairs, only tub, no heat/air, no transport, etc.

    28. The Round Up Now Mrs. So and So, was there anything else you forgot to mention? Anything else you wanted the doctor to know/check today? Any other concerns? Any other medications, herbals, over the counter drugs?

    29. Resources for Triage Pediatric Telephone Advice, Barton D. Schmitt, Lippencott, Williams & Wilkins, 2004 Adult Telephone Protocols: Office Version. 2nd Edition. David Thompson, MD. 2009 Guidelines for Telephone Triage (Dermatology). Carolyn Buppert, JD, CRNP. Dermatology Nursing, 2009;21(1):40-41

    30. Resources for Triage Epic Systems Corporation, (adult/peds) info@epicsystems.com HealthLine Systems, Inc., (adult/peds/women’s health) www.helathlinesystems.com

    31. Triage Resources McKesson, CareEnhance Systems www.mckesson.com

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