Instructions For Use Of The Nursing Assessment And Care Record-Books Pdf

Instructions for use of the Nursing Assessment and Care Record
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Table of Contents,GUIDELINES FOR USING THIS DOCUMENT. NURSING ASSESSMENT AND RECORD,Intake and Output,Fluid Therapy Sheet IV and or HDC. Signature Log, Braden Scale for Predicting Pressure Score Risk Nutrition. Nutrition Interventions,Patient Care Record Narrative Notes. Patient Assessment Record,Central Nervous System,Cardio Vascular system.
Additional Isolation Precautions,Compression,Oral Status. Respiratory System,Assisted Ventilation,Auscultation. Chest Tubes,Gastro Intestinal System,Genito Urinary System. Incisions and Drains,Musculoskeletal System,Activities Of Daily Living. Respiratory,Pain Management,Braden Interventions,Miscellaneous.
REFERENCES, The booklet is a 24 hour assessment based record It includes the following. Signature Log,Fluid Balance Intake Output,Intravenous Flow Sheet. Braden Scale with suggested Interventions and Nutrition Interventions. Patient Care Record,Three two page assessment forms. Activities of Daily Living, Additional assessment tools may need to be added including items such as Vital. Signs record neurovascular assessment tool pain flow assessment sheet. The purpose of the Nursing Assessment and Care Record Booklet is to. Consolidate and communicate patient assessment and care information to. facilitate continuity of care,Standardize documents between the sites.
GUIDELINES FOR USING THIS DOCUMENT, It is expected when possible that the physical assessment and documentation be. completed within the first half of your shift, Throughout the document please be sure to use the symbols outlined in. legends provided, A patient identification label is placed at the top right hand corner of each. Signature Log Place your legible printed name signature and initials in the. appropriate boxes, Space is provided for the date time and initials of assessor s on each. assessment page Joint patient assessments require co signatures by. both all staff completing the assessment, Applicable boxes are check marked and blanks are filled in if appropriate.
Checkmarks on the ADL section of the document indicate an. intervention action has been performed, If assessment of a body system is not required check off the Not. If a category does not apply to your patient i e vaginal flow check off the. NA not applicable this indicates that this section does not apply to your. Assessment findings that are abnormal or that need further description are. asterisked More explanation is required on the Patient Care Record. On either the Intake and Output or ADL sections of the document unused. columns can be re labeled to provide enough room to write. Complete versus Focused Assessment, All assessments will be charted on the Nursing Assessment. Record portion of the Medical and Surgical Patient Care Record. Complete Assessment, Definition Head to toe assessment covering all systems Every section of. the nursing assessment and care record must be completed. Complete assessment is required on the day and evening shift for all. Complete assessment will be done twice a day e g 0800 and 2000. Complete assessments are required on admission from the Recovery. Room Emergency Room another unit direct admission or from. another hospital,Focused Assessment, Definition Assessment directed to one or more body systems The extent. of focused assessments is largely based on nursing judgment considering. factors such as patient acuity patient stability and information from shift. report Focused assessment could be done on night shift or when a staff. member takes on additional patient assignments during the shift or at shift. In these situations a complete versus focused assessment is at the. discretion of the nurse based on patient acuity Communication. between shifts is essential to ensure that the admission assessment. process is complete, A complete or focused assessment may be required depending on staff.
changes patient arrival time on units and the priority of the RN or LPN patient. assignment, Example If you are working an eight hour shift then switch to a twelve hour. shift keeping the same patients complete one assessment If you have a. change in assignment then you need to do a focused assessment at a. minimum on the new patients you will care for, On night shift either a complete or focused assessment is required depending. on the acuity of patients or unit specific policies. Documentation Frequency, The frequency of documentation and the amount of detail are dictated. by a number of factors including, The policies and procedures of the practice setting. The complexity of the health problem, Degree to which the client s condition puts them at risk.
Degree of risk involved in the treatment or care, According to the Canadian Nurses Protective Society CNPS the. recording of nursing care provided should be more comprehensive in. depth and frequent if the client is very ill has unstable health care needs. and unpredictable outcomes Alberta RN 2007 p 12,NURSING ASSESSMENT AND RECORD form 54928. Document the Date your shift started i e If your night shift started at 23 30. hours on December 30th and you finish your shift at 07 45 on December 31st. you would write December 30th to December 31st as the date in which you. received the patient into care Use 24 hour clock for time. There must be two dates recorded on the chart indicating the span of time over. which the information is recorded,Intake and Output. This record covers a 24 hour period, Intake and output is to be documented in the corresponding boxes of time. Each shift is responsible for totaling their intake and output and for. clearing the pump s, Sources of intake or output can be noted at the top of the form and the.
corresponding volume documented at the appropriate time. If a patient requires hourly totals they are to be added together at the end of. the shift to produce a shift total At this time the IV pump total volume. infused would be cleared, The numeric value recorded as urinary bladder scan results are not included. in the output total as this is not actual output but a measurement of bladder. stretching, At the end of the 24 hour time period the total intake from the day evening. and night shift is calculated and documented on the 24 hour intake line. At the end of the 24 hour time period the total output from the day evening. and night shift is calculated and documented on the 24 hour output line. Calculate the patients 24 hour balance by subtracting the output from the. intake Indicate if the 24 hour fluid balance is negative or positive by checking. the appropriate box, Depending on unit policy and patient need totals of specific fluid intake or. output can be tallied for the shift at the lower end of the column where it. indicates Totals, It is not possible to accurately calculate 24 hour fluid balance when the. patient is incontinent,Fluid Therapy Sheet IV and or HDC.
Fluid therapy is to be documented at the beginning of the shift as well as. throughout the shift At the beginning of a shift document the IV s and or. HDC that is infusing on your initial round Throughout the shift any IV fluid. that is hung or IV access change i e saline lock is to be documented on the. Fluid Therapy Record Indicate time type site location cannula size action. amount and type of solution rate in mL hour tubing changes injection cap. changes reason for removal and initials When appropriate use the legend. If more than one solution is infusing into one lumen of the access device put. a bracket around the IV solutions that are infusing into the lumen. Cannula size For CVC PICC document the ports by indicating Distal. Medial or Proximal, If your patient does not have any of the access types check off NA. Braden Scale for Predicting Pressure Score Risk Nutrition. Completed on admission and subsequently once every 24 hours on the day. The assessment categories and definitions are provided for reference Check. the boxes that apply to your patient and total the score Initial and date. Fill in or check off the appropriate Braden Scale interventions that apply to the. By checking the Care Protocol Risk Category you are indicating the plan of. care for performing pressure relieving interventions The time when these. interventions are completed should be indicated in the ADL Braden. Interventions section and narrative documentation as required. Sensory 1 Completely Limited 2 Very Limited 3 Slightly Limited 4 No Impairment. Perception Unresponsive does not Responds only to Responds to verbal Responds to verbal. Ability to moan flinch or grasp painful stimuli Cannot commands but cannot commands has no. respond to painful stimuli due to communicate always communicate sensory deficit which. meaningfully diminished LOC or discomfort by moaning discomfort or need to be would limit ability to. to pressure sedation OR limited or restlessness Or has turned OR has some feel or voice pain or. related ability to feel pain over a sensory impairment sensory impairment discomfort. discomfort most of body which limits the ability to which limits ability to. feel pain or discomfort feel pain or discomfort,over half of body in 1 or 2 extremities. Moisture 1 Constantly Moist 2 Very Moist 3 Occasionally Moist 4 Rarely Moist. Degree to Skin is kept moist Skin is often but not Skin is occasionally Skin is usually dry. which skin is almost constantly by always moist Linen moist requiring an extra linen only requires. exposed to perspiration urine etc must be changed at linen change changing at routine. moisture Dampness is detected least once a shift approximately once a intervals. every time patient is day,moved or turned, Activity 1 Bedfast 2 Chair fast 3 Walks Occasionally 4 Walks Frequently. Degree of Confined to bed Ability to walk severely Walks occasionally Walks outside the. physical limited or non existent during day but for very room at least twice a. activity Cannot weight bear short distances with or day and inside every. and or must be assisted without assistance two hours during. into chair or wheelchair Spends majority of each waking hours. shift in bed or chair, Mobility 1 Completely 2 Very Limited 3 Slightly Limited 4 No Limitations. Ability to Immobile Makes occasional slight Makes frequent though Makes major and. change and Does not make even changes in body or slight changes in body frequent changes in. control body slight changes in body extremity position but or extremity position position without. position or extremity position unable to make frequent independently assistance. without assistance or significant changes,independently.
Nutrition 1 Very Poor 2 Probably 3 Adequate 4 Excellent. Usual food Never eats a complete Inadequate Eats over half of most Eats most of every. intake meal Rarely eats more Rarely eats a complete meals Eats a total of 4 meal Never refuses. pattern than 1 3 of any food meal and generally eats servings of protein a meal Usually eats. offered Eats 2 servings only about of any meat dairy products a total of 4 or more. or less of protein meat food offered Protein each day Occasionally servings or meat and. or dairy products per intake includes only 3 will refuse a meal but dairy products. day Takes fluids servings of meat or will usually take a Occasionally eats. poorly Does not take a dairy products per day supplement if offered between meals. liquid dietary Occasionally will take a OR is on tube feeding Does not require. supplement OR is NPO dietary supplement OR or TPN regimen which supplementation. and or maintained on receives less than probably meets most of. clear liquids or IVs for optimum of liquid diet or nutritional needs. more than 5 days tube feedings, Friction 1 Problem 2 Potential Problem 3 No Apparent. and Shear Requires mod max Moves feebly or Problem. assist in moving requires minimum Moves in bed and in. Complete lifting without assistance During a chair independently and. sliding against sheets is move skin probably has sufficient muscle. impossible Frequently slides to some extent strength to lift up. slides in bed or chair against sheets chair completely during. requiring repositioning restraints or other move Maintains good. with max assistance devices Maintains position in bed or chair. Spasticity contractures relatively good position at all times. or agitation lead to in chair or bed most of,almost constant friction the time but. occasionally slides,Nutrition Interventions, Mark NA if anticipated LOS less than 3 4days unless patient is perceived. to have high nutrition risk or if nutritional consult specifies. Circle the appropriate level of feeding assistance needed self assisted total. Document the type of diet from the legend that the patient consumed at. breakfast lunch and supper This can change from meal to meal Example. NPO breakfast regular lunch and supper, Document the estimated meal intake for breakfast lunch and supper This. should be documented as a percentage Please use the following percentage. values to indicate the approximate amount of food consumed 0 25 50. Document if a supplement is given Supplements may be given on the meal. trays if ordered by the dietician breakfast lunch and supper Document the. estimated supplement intake This should be documented as a percentage. Please use the following percentage values to indica. If assessment of a body system is not required check off the Definition Head to toe assessment covering all systems Every section of the nursing assessment and care record must be completed Complete assessment is required on the day and evening shift for all patients Complete assessment will be done twice a day e g 0800 and 2000 Complete assessments are required on admission from

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