DOCUMENTATION AND DELEGATION
Objectives: Upon completion of this class, the student will be able to:
1. Discuss purposes of client records;
2. Describe how forms in the client record document the nursing process;
3. Identify guidelines for effective recording that meets legal and ethical standards;
4. Identify commonly used abbreviations that are used in clinical documentation;
5. Describe the components of the client care plan;
6. Discuss the RNs role in delegation of client care;
7. Describe the pathology and nursing process of the patient with COPD;
8. Apply the above content to the COPD patient.
9.
I.Chronic Obstructive Pulmonary Disease (COPD)
4th leading cause of death in US; caused by cigarette smoking
Unlike actue illness, lung tissue never regains resiliency
A. Pathology: progressive destruction of airways
1. Chronic Bronchitis: excessive bronchial mucous secretion; cigarette smoking, chronic inflammation. Persistent cough for more than 3 mo over 2 consecutive years. Goblet cells multiply and make mucus, obstructing airways, in response to inflammation. Cilia are impaired; defenses are down, recurrent infections occur.
2. Emphysema: alveolar destruction, deficit of alpha1-antitrypsin (enzyme that prevents breakdown of tissue in lungs.) No alveoli means no individual units in the apartment building—no exchange surface area [Jett Chinn.] Smokers. Support tissue and elasticity fail, and less air is brought in and out.
B. Manifestations:
1. History: smoking, cough, dyspnea
2. PE: wheezes, rhonchi, decreased breath sounds, barrel chest
3. Diagnostic findings: ABG abnormalities
C. Management:
4. 1.Diagnosis: tests establish if it’s bronchitis or emphysema. Assess resp status, compare to status after treatment:
· Pulmonary function testing: which diagnosis?
· Ventilation-perfusion scanning: determines air in vs. air perfused; assesses ‘dead spaces’
· Serum levels of anti-trypsin enzyme
· ABGs: eval gas exchange, hypoxia, resp alkalosis
· Pulse ox: levels less than 95%
· Exhaled CO2 is also measured to assess perfusion
· Complete Blood Count: RBCs increase in # when perfusion impaired
· Chest XRay may sho flattening of diaphragm due to hyperinflation
5. 2. Smoking cessation: prevents and improves COPD, longer survival
6. 3. Medications: vaccines against flu and pneumonia, broad spec antibiotics—sometimes prophylactically, steroids, bronchodialators help w/ QOL, enzyme replacement therapy.
7. 4. Oxygen: good Tx, but it can increase “PaCO2” [hypercapnia- the condition of having an abnormally high concentration of carbon dioxide in the blood] and can increase sleepiness, and lead to resp failure.
8. 5. Pulmonary Rehab
9. 6. Surgery
D. Nursing Process
10. Assessment
11. Nursing Diagnosis
12. Expected Outcomes
13. Planning and Implementation
14. Evaluation
II.DOCUMENTATION
A. Purposes
1. Communication
2. Planning Client Care
3. Auditing Health Care providers: maintain JACHO standards
4. Research
5. Education
6. Reimbursement
7. Legal and ethical aspects: ANA, HIPAA
8. Example: As a new Student Nurse, what are your responsibilities regarding charting on your patient?
B. Documentation Systems
1. Source–oriented record: traditional chart; forms, narrative
2. Problem-oriented medical record: progress notes, SOAP format
3. PIE method
4. Focus charting
5. Charting by exception CBE)
6. Computerized documentation: EBP
7. Case management
8. Example: You will be working in many different hospitals while a student nurse. What are your responsibilities when each place has a different charting system?
C.General Guidelines: Why are these important?
1. Date and time
1. Timing: ASAP
2. Legibility
3. Permanence: ball point black pen
4. Accepted terminology: DonÕt be creative!
5. Correct spelling
6. Signature
7. Accuracy: How do you correct errors in charting?
8. Sequence: What if you forget to chart an important nursing intervention?
9. Appropriateness
10. Completeness
11. Conciseness: donÕt leave any blank spaces with narrative charting
12. Legal Prudence
III. Reporting
A. Change of shift report: What is the purpose?
B.Telephone report
C.Telephone or verbal orders: Can you take these as an SN?
D. Care Plan conference
E. Nursing Rounds
IV. Client Care Plans
A. Types
1. Individualized
2. Standardized
B. Components
C. Critical Pathways
V. Delegation of Client Care
According to RN Practice Act by state
RN is still the accountable for all delegated tasks
UAP or CNA: can receive training in skills like changing clean dressings, suctioning trachs
RN decides what and when to delegate, must know parameters and what’s safe, must supervise all outcomes
What can’t be delegated:
Charting
Assessments
Care planning
Referral forms
Pain management activities
Checking advance directives [DNR]
Organ Donation wishes [RN or LVN]
Discharge plan
RN Diagnosis
§ 2725.3. Functions performed by unlicensed personnel
(a) A health facility licensed pursuant to subdivision (a), (b), or (f), of
Section 1250 of the Health and Safety Code shall not assign unlicensed
personnel to perform nursing functions in lieu of a registered nurse and
may not allow unlicensed personnel to perform functions under the direct
clinical supervision of a registered nurse that require a substantial amount
of scientific knowledge and technical skills, including, but not limited to, any
of the following:
(1) Administration of medication.
(2) Venipuncture or intravenous therapy.
(3) Parenteral or tube feedings.
(4) Invasive procedures including inserting nasogastric tubes, inserting
catheters, or tracheal suctioning.
(5) Assessment of patient condition.
(6) Educating patients and their families concerning the patient’s health
care problems, including postdischarge care.
(7) Moderate complexity laboratory tests.
(b) This section shall not preclude any person from performing any act or
function that he or she is authorized to perform pursuant to Division 2
(commencing with Section 500) or pursuant to existing statute or regulation
as of
5 Rights:
- Right person: right person delegating; who can legally do the delegated task?
- Right circumstances: setting, supplies, skills
- Right Task: is it a legally delegate-able task?
- Right Communication: clear instructions and expected outcomes
A. RN Delegation
1. Def: Òtransferring to a competent individual the authority to perform a selected nusing task in a selected situationÓ (National Council of State Boards of Nursing)
2. RN responsibilities:
a. decision which tasks can be delegated, safe, supervise outcomes
b. know legal scope of practice of other providers
c. know clinical competency of providers
3. Parameters of delegation
a. right task
b. right circumstances
c. right person
d. right communication
e. right supervisor
VI.Critical thinking exercises
A. Mr. Page is an 80 yo man admitted with a diagnosis of COPD and possible pneumonia. He complains of general malaise and a frequent productive cough worse at night. Vital signs are: BP 150/90, pulse 92, respirations 28, temperature 38.3C. During your initial assessment he coughs violently for 45 seconds without expectorating. His lungs have wheezes and rhonchi in both bases. Differentiate between objective and subjective data in this case example. Chart this assessment data on narrative nurses notes.
B. The nurse positions Mr. Page in a semi-FowlerÕs position, encourages increased fluid intake, and gives Tylenol 650 mg PO as ordered for fever. One hour later the client is resting in bed. VS are: BP 130/86, pulse 86, respirations 22, temperature 37.7C. He states he has been unable to sleep. His fluid intake has been 2200 mL of water. Use the given information to write a nurseÕs progress note using the Charting by Exception format.
C. At the end of your shift you have identified Òdeficient fluid volumeÓ as a nursing diagnosis for this patient. Since his admission he has had fluid intake of about 600 ml and his urine output was 300 ml of dark concentrated urine. His temperature is back up to 38.3C, his mucous membranes are dry, and he states he feels very weak. What should be include in the change of shift report?
D. Several days later, following treatment with IV antibiotics, Mr. Page is feeling much better and preparations are being made for discharge. He is to take Keflex 500 mg every 6 hours for the next 10 days, continue to drink extra fluids, and get extra rest. He lives alone. Although he is generally cooperative, he does not like drinking water or taking pills. He is to make an appointment with his doctor for 1 week from today and should call the doctor if he develops symptoms of recurrence. Write discharge notes.
E. Define the following medical terminology:
E. Define the following medical terminology:
1. adenocarcinoma:
gland cancerous tumor: A malignant neoplasm of epithelial cells with a glandular or glandlike pattern.
2. areflexic:
no reflexes
3. meningitis:
meninges inflamed
4. microalbuminuria:
small (white) albumin in urine
5. colonoscopy:
checking out (examination of) the colon
6. endoscopy:
inside/interior examination: ‘means “looking inside”’ many different –oscopy procedures fit under this heading: GI tract, respiratory tract, reproductive, and colonoscopy
6.5 Colposcopy [colpo-scopy]
Examination of the vagina [colpo=vagina]
7. anticoagulant:
against coagulation
8. edema:
swelling
9. appendectomy:
appendix removal/excision
10. colectomy:
colon excision
11. coloscopy:
Examination of the colon
12. contralateral:
against/opposite side; on the opposite side of the body
13. diplopia:
diplo + opis: double+vison
14. gynecology:
woman/female sex study
15. pneumonia:
breathe/lung inflammation [pneuma=breathe or lung]
16. pneumonitis:
breath/lung inflammation
17. apnea
a-without; pnea-breathing
18. post-operative:
after operation
19. pre-operative:
before operation
20. thoracotomy:
opening into the thorax or part of the thorax
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