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Slide Notes
6 hours
24.0 Use appropriate verbal and written communications in the performance of nursing functions
24.01 Receive and give oral report of patient's status.
24.02 Report and record objective, pertinent observations.
24.03 Maintain current documentation.
24.04 Document changes in patient behavior and mental awareness.
24.05 Obtain specified data from patient and family.
24.06 Define and explain the steps in the nursing process and the role of the licensed practical nurse in that process.
24.07 Utilize nursing principles to assist with the patient's plan of care.
SBAR
give/ receive report
H & P
Care Plan — Guest Speaker Mrs. Patti Cummings — 1 hour ?
also the nursing process
24.0 Use appropriate verbal and written communications in the performance of nursing functions
24.01 Receive and give oral report of patient's status.
24.02 Report and record objective, pertinent observations.
24.03 Maintain current documentation.
24.04 Document changes in patient behavior and mental awareness.
24.05 Obtain specified data from patient and family.
24.06 Define and explain the steps in the nursing process and the role of the licensed practical nurse in that process.
24.07 Utilize nursing principles to assist with the patient's plan of care.
SBAR
give/ receive report
H & P
Care Plan — Guest Speaker Mrs. Patti Cummings — 1 hour ?
also the nursing process
Nursing functions
Published on Dec 07, 2015
No Description
MORE DECKS TO EXPLORE
PRESENTATION OUTLINE
Nursing Functions r/t
communications/plans
6 hours
24.0 Use appropriate verbal and written communications in the performance of nursing functions
24.01 Receive and give oral report of patient's status.
24.02 Report and record objective, pertinent observations.
24.03 Maintain current documentation.
24.04 Document changes in patient behavior and mental awareness.
24.05 Obtain specified data from patient and family.
24.06 Define and explain the steps in the nursing process and the role of the licensed practical nurse in that process.
24.07 Utilize nursing principles to assist with the patient's plan of care.
SBAR
give/ receive report
H & P
Care Plan — Guest Speaker Mrs. Patti Cummings — 1 hour ?
also the nursing process
24.0 Use appropriate verbal and written communications in the performance of nursing functions
24.01 Receive and give oral report of patient's status.
24.02 Report and record objective, pertinent observations.
24.03 Maintain current documentation.
24.04 Document changes in patient behavior and mental awareness.
24.05 Obtain specified data from patient and family.
24.06 Define and explain the steps in the nursing process and the role of the licensed practical nurse in that process.
24.07 Utilize nursing principles to assist with the patient's plan of care.
SBAR
give/ receive report
H & P
Care Plan — Guest Speaker Mrs. Patti Cummings — 1 hour ?
also the nursing process
Photo by garryknight
Verbal
- Report/Hand off
- SBAR
- Interview
24.02 Report and record objective, pertinent observations.
SBAR -- break into groups of 2 collect vital signs of partner and have partner fein the symptoms on note slip...
- hospital specific SBAR
24.01 Receive and give oral report of patient's status.
Use SBAR from Above and have the students give and receive report to another student in class (number them so they are not paired with the student that they assessed...
24.05 Obtain specified data from patient and family.
during the interview process
Practice the H and P
H&P
History of Present Illness
onset
duration
intensity
relief
worse
location
demonstration if possible
medications for this problem
effects on other body systems
impact on rest
impact on social/work life
what are the patents concerns, thoughts, diagnosis
any previous medical interventions
Past Medical History
client age
other medical diagnosis (onsets and treatments)
surgical intervention/history (procedures with dates and reasons)
medications regularly taken (names and dosages)
other medical problems (open-ended questions)
hospitalizations (open-ended questions)
allergies (drugs and foods then description of the reaction)
smoking (frequency, ppd/years, quit), drinking (frequency, and amount, and type)
family history
siblings and their problems
parents and their problems and death
history of cancers
Photo by Pop!Tech
Documented
- Written
- Current
- Changes
- Subjective/Objective
24.02 Report and record objective, pertinent observations.
Instruct the students to take the notes that you have made on the interaction of the H & P from previous slide and complete the documentation...
24.03 Maintain current documentation.
how do we do this
24.04 Document changes in patient behavior and mental awareness.
subjective vs. objective Information
accurate, specific, as soon as possible, fact based, quotes,
"if it wasn't documented it wasn't done"
Photo by marynbtol
So What's the Plan
- delivering holistic,
- patient-focused care
- moving from illness to wellness
- use the nursing process
24.07 Utilize nursing principles to assist with the patient's plan of care
24.02 Report and record objective, pertinent observations.
24.03 Maintain current documentation.
Care Plan — Guest Speaker Mrs. Patti Cummings — 1 hour ?
also the nursing process
to follow
Photo by surroundsound5000
Process
- Assessment
- Diagnosis (Nursing Style)
- Outcomes/Planning
- Implementing
- Evaluation
also the nursing process
Assessment
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.
Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.
Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.
Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.
Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.
Assessment
An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.
Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.
Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.
Implementation
Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.
Evaluation
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.
Photo by Dylan Luder
