Professional Documents
Culture Documents
Parts: OBC
Types: DN
a. Inspection to look b. Palpation to touch; try to palpate abnormalities c. Percussion to tap; make a sound using hand to
the body of the patient
a. Cephalocaudal head to foot b. Body System system by system examination c. System Review you are only focusing on one
system ORGANIZATION ELEVEN TYPOLOGY: HNEASCSRSSV DOCUMENTATION Recording the timely information without the nurses interpretation You will write as is No more, no less; what you see is what you write; record only what you can do; failure to do so will result to negligence, malpractice, or fraud
CHARACTERISTICS: FAT
1. Factual realistic; accurate 2. Actual really happened 3. Timely updated; taken from the time of
assessment DIAGNOSIS THREE PARTS: PES 1. 2. 3. Problem Etiology Signs and Symptoms
VALIDATION Confirmation; making sure False negative: wrong but looks true False positive: true but looks wrong*
1. Compare compare taken data from normal data 2. Clarify always clarify the information. Be sure
that the data you get from pt is true
1. Pts Beliefs take note of religion 2. Resource Available consider the financial
status of pt and capacity of the hospital; eg manpower 3. Pts Priority some pts prioritize life, some go for money, some for belief
Nursing Intervention should be holistic perceiving the person as a whole human being; all aspect of person is equally recognized Provide support person to pt When pt is asking something, give appropriate answer with gesture When doing intervention, give dignity and respect to pt There should be adaptation of Nursing activity to the pts activity While nurse is doing something, make it a part of the pts activity Right-handed, put IV on the left Base nursing knowledge on a problem, so that there will be no conflict between theoretical and applied When you are giving intervention to pt, make sure you give health teaching to pt Ensure safety for every nursing intervention Clearly understand intervention for implementation; justify reasons for actions
2. Documenting Nursing Care Plan write what 3. Pts Chart / Records has three types: a. Traditional - used by medical practitioners
to record pts condition before and after treatment b. Narrative not specific; mostly used by nurses for their convenience; narrating what happened; a paragraph of events c. Problem-Oriented record that only focuses on the problem and only the problem DIFFERENT FORMS RECORDS: KF / SHEETS OF PTS
Sentinel Event happened in the hospital; may be death or a serious injury that caught attention; significant phenomenon that must be known Root Care Analysis you will identify the factors / causes of the phenomenon; source of sentinel event; what triggered the action Audit Review of Record; check or recheck record; audit for the sake of reassessing a. Retrospective Auditing past records b. Concurrent Auditing present records