Michelle Pearson-Smith. NURS 6639 Fundamentals of Nursing: Documentation and the Role of the RN

Transcription

1 Fundamentals of Nursing: Documentation and the Role of the RN Class Location: Lewis Clark State College (500 8 th Ave.) Sacajawea Hall: Conference Room A Class Date/Time: Wednesday December 7 th, 2011/ Purpose: To provide clinical practicum students a complete guide to the process and importance of the paper trail in providing exceptional patient care Prerequisites: Required reading: Chapter 26 pgs from course Textbook: Potter & Perry. (2010). Fundamentals of Nursing (7 th Ed.). Elsevier-Health Sciences Division. St. Louis: Mosby. ISBN: Objective: Construct a thorough narrative assessment note of a head to toe patient exam based on one of the case studies provided in the learning environment. Learning Theory & Instructional Design Model: Cognitive Flexibility Theory & ASSURE Model Technologies Used: Computer and Overhead projector or ELMO Lesson Plan: Length of time 5 minutes Analysis of learners Documentation Race Handout (Attachment 1) Lesson Outline Aid cues & Resources Evaluation Strategies Reinforce before introducing the handout that Documentation must be: 1. Factual 2. Accurate 3. Complete 4. Current 5. Organized 15 minutes Faculty led Discussion Discussion should consider that students will have previously read Potter & Perry textbook, chapter 26 Documentation & Informatics. Completed handout collected by instructor after time allotted to complete has run out

2 Topics to address/discuss: 1. Patient Confidentiality 2. Purpose of 3. Types of 4. Standards of 5. Reporting as a form of documenting 6. Orders in the process 7. Nursing Informatics 10 minutes Review of Pre-test Documentation Race Handout Given Back to students (peer grader) 5 minutes Description/Explanation of Assignment Key Example of Handout projected for students to review during discussion (Attachment 2) Present Case Study (Attachment 3) 15 minutes Assignment completion Allow quiet/focused time for students (as individuals) to complete using format of individual choosing discussed in Chapter minutes Review of Assignment Choose 1 individual to project completed assignment overhead for class discussion. Evaluate case study relevance and recognition by level of student Evaluate the length & appropriateness of time allowed Consider requiring group work for assignment completion instead of individuals Lead discussion regarding based on 5 key principals as well as the discussion topics.

3 Attachment 1 Documentation Race Instructions: Review the below, you will have 60 seconds to read and evaluate. When instructed you will begin writing your concerns regarding the. You will have 30 seconds and the group will discuss as a whole. 11/30/11: Patient having a hard time catching his breath. Respirations are labored. VS: 112/70, 120, 32, SpO2 90%, temp F. Skin color is pale, skin warm and wet, lips and nail beds are discolored. Patient alert and oriented x3. Breath sounds auscultated crackles and wheezes over lower lobes. Elevated head of bed to help breathing. Obtained ABG. O2 placed and remained at bedside to calm patient M Smith Concerns:

4 Key: Attachment 2 Documentation Race Instructions: Review the below, you will have 60 seconds to read and evaluate. When instructed you will begin writing your concerns regarding the. You will have 30 seconds and the group will discuss as a whole. 11/30/11(time): Patient (What patient, identify patient) having a hard time catching his breath (subjective...how could we make this objective) Respirations are labored (could be more objective how) VS: 112/70, (what does this number represent) 120, (what does this number represent) 32, SpO2 90% (what oxygen level was this reading obtained on), temp F (where was this temperature obtained). Skin color is pale, skin warm and wet (is this appropriate), lips and nail beds are discolored (subjective how can we make it objective). Patient alert and oriented x3. Breath sounds auscultated crackles and wheezes over lower lobes (needs to be more specific). Elevated head of bed (to what degree or position) to help breathing (subjective consider rewording). Obtained ABG (who did, from where, oxygen at the time, what did you do with it). O2 placed (how much, via what device) and remained at bedside to calm patient M Smith (credentials)

5 Case Study Attachment 3 Rodney Paige is a 76 year old man retired from working at the local saw mill as an equipment operator. He is admitted for replacement of his left total knee related to osteoarthritis. This is his second postoperative day on your unit and he is anticipating discharge today. His night was uneventful however this morning, he complains of general malaise, feeling freezing, and a frequent cough. He describes his pain to the left knee as continuous aching and rates his pain as 4/10. He has an ACE wrap to the left leg, it is clean and dry. Pulses are palpable +2 to bilateral lower extremities, and there is non-pitting edema to his left foot. Vital signs are as follows: blood pressure, 150/90 mmhg; pulse 92 beats per minutes, respirations, 22 breaths per minute/ and temperature degrees Fahrenheit. During your initial assessment he coughs violently for seconds without expectorating. His lungs have rhonchi in both bases and are diminished on the right. You get him up to the chair per doctor s order for breakfast once your assessment is complete and will return with his routine morning medications. Instructions: In the space provided below, document on the case study using the format of your choice. (Narrative, SOAP, PIE, etc.)